Some drugs require prior authorization. This means that members must receive approval from Health Net before a drug will be covered. Our drug lists identify which drugs require prior authorization.
To request prior authorization, the prescriber must complete and send us a Prior Authorization / Formulary Exception Request Form (PDF). We also require a supporting statement from the prescriber explaining why a particular drug is medically necessary for the member's condition.
Requests can be faxed or mailed to the contact information on the form.
Once we receive the prior authorization request, it is reviewed to determine if it meets our approval criteria. In this determination, we explain whether the request is approved or denied. If a request is denied, the member has the right to appeal our decision.
In some cases, step therapy is required before we will cover a drug. This means that members must try one drug before we will cover another drug for the same medical condition.
Example: If Drug A and Drug B both treat the same medical condition, we may not cover Drug B unless the member tries Drug A first. If Drug A does not work, we will then cover Drug B.
In the example above, if the member’s recent claims history shows use of Drug A, we will cover Drug B.
Health Net may override a step therapy requirement for some reasons. To ask for an override to a step therapy requirement, the prescriber must complete a Prior Authorization Request Form (PDF) and provide one of the below items:
- A statement that the member tried and failed the step therapy drug(s)
- Medical justification about why the step therapy drug(s) are not appropriate for the member
View our Provider Prior Authorization Guidelines for detailed information about our approval and step therapy criteria.