Pharmacy Benefits / Resources
We created this Pharmacy Benefits Member Guide to make it easier for you to understand and get the most from your pharmacy benefit coverage. It will also give you important cost-saving options. Since some plans may differ from others, you'll want to log in to access information about your specific plan benefits.
Our three-tier plans give you both generic and brand name prescription drug coverage. You get easy-to-use pharmacy programs that offer the convenience you want with the value you're looking for.
Some plans may also have a Specialty Tier, which is covered under the pharmacy benefit. Specialty Tier drugs will usually be provided by a specialty pharmacy identified by us. Most of these drugs require prior authorization. Please refer to your plan documents and our Preferred Drug List for specific coverage, copay and tier information.
Some plans have an annual deductible – the amount you pay before your plan benefits will pay for covered services. If your plan has an annual deductible, it means you pay:
- The full price of your prescription until you reach the deductible amount; then
- Only the copay or coinsurance amount, based on your benefit plan, after you've met the deductible amount
Check your plan documents to see if you have a plan deductible and how it works with your benefit plan.
We have an extensive pharmacy network throughout the country, so it's easy to find a network pharmacy near your home or office.
Network pharmacies include major supermarket-based and privately owned pharmacies throughout Oregon, as well as major pharmacy chains throughout the United States. When you fill your prescriptions at one of our network pharmacies, you receive your prescription drugs at the highest available benefit coverage under your plan. By using an out-of-network pharmacy, you may have to pay full price for your prescription.
Ensuring a smooth transition of your current drugs is an important first step for new members. You'll breathe easier knowing your current drugs are covered by your Health Net plan.
View our drug list to see if your drug is covered. Once you find it's on the list, you're good to go. If your drug requires prior authorization, you can either start the transition process or talk to your doctor about other drugs on our drug list that will work just as well for you.
How to transition your drugs
You can transition select maintenance drugs – those you take every day – to your new Health Net pharmacy coverage by following these simple steps:
- Review the Prescription Transition form included in your enrollment packet
- A separate form is required for each family member transitioning drugs
- Make sure each drug you wish to transition, and which requires prior authorization, is listed on the form
- If your drug is not listed on the form, you may be required to have your doctor call us for prior authorization to ensure coverage
- The form(s) must be completed and submitted within the first three months of eligibility with Health Net
- Fax or mail the completed form(s) to the fax number or address shown on the form
When we receive the form(s), authorization for each eligible drug will be entered into the pharmacy claims processing system, so you can obtain your drugs with your new Health Net pharmacy coverage.
If your doctor prescribes a drug that requires prior authorization, and is not on the Prescription Transition form or our drug list, your pharmacy will contact your doctor to either suggest an alternative drug covered by us and/or will ask your doctor to contact us to request coverage for the drug they prescribed. This is common practice followed by all pharmacies and doctors.
If you're a new or existing Health Net member and your doctor orders a new drug, check to see if the drug is on our drug list and if it requires a prior authorization. If it does require a prior authorization (noted on the drug list with a "PA"), ask your doctor to contact Health Net to request coverage for the prescribed drug.
What is prior authorization?
Prior authorization is the process of getting approval from us for certain drugs before they are covered. This process is one of the ways we ensure our members get the safest drugs with the best value. We will approve prior authorization requests when medical necessity has been confirmed.
Our mail order pharmacy program gives you the convenience of having your daily maintenance drugs delivered to your home or office. You also get the added benefit of receiving an extended supply of your prescription drugs. No need to think about refills every month. Our mail order pharmacy may also help you lower your out-of-pocket costs.
Save time and money with these simple steps:
- Ask your doctor about generic drugs that may work for you
- Fill prescriptions at our network pharmacies
- Be sure your doctor prescribes drugs on our drug list and ask if your drugs require prior authorization
- Fill your maintenance drugs through our mail order pharmacy program, when possible