Coverage Determinations and Redeterminations for Drugs
If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, you may contact us and request a coverage determination.
You can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested.
- You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
- You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
To request an exception, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Some drugs require prior authorization. This means that you must receive approval from Health Net before the drug will be covered. The prior authorization process ensures members are receiving the correct drug combined with the best value for their medical condition.
- Health Net 2018 Medicare Part D Pharmacy PA Criteria (pdf)
- Looking for Prior Authorizations for Medical Services?
To request prior authorization, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. Generally, Health Net will only approve a prior authorization request for and exception if preferred alternative drugs or utilization restrictions would not be as effective in treating your condition and/or would cause you to have harmful medical effects.
To request an exception or to obtain prior authorization, you or your prescriber can email, fax or mail a coverage determination request to the contact information listed below. A coverage determination can also be requested by calling Member Services. If a request is sent by email, be sure to include your name, Health Net member ID number and telephone number, as well as the details of the request. The Member Medicare Part D Coverage Determination Request Form can be used as a guide of information to include. With the request, we require a supporting statement from your prescriber explaining why a particular drug is medically necessary for your condition.
Once we receive the coverage determination request, it is reviewed to determine if it meets the requirements for approval. We must make our decision regarding an exception or prior authorization request and respond no later than 72 hours after we have received your prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the request (this is sometimes called an adverse coverage determination), you can appeal our decision. Information on how to file an appeal is included with the denial notification.
If waiting up to 72 hours for a "standard" decision could seriously harm your health or your ability to function, you or your prescriber can ask us to make a "fast" decision. A fast decision is sometimes called an expedited coverage determination and applies only to requests for Part D drugs that you have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. To request a fast decision, contact us by fax or by calling Member Services. We will make our decision and respond to all requests as quickly as your health condition requires.
Members: Contact us
Calls received after hours will be handled by our automated phone system and a Health Net representative will return your call on the next business day.
Submit a question to our Member Services Team
Health Net Pharmacy Department
Attn: Prior Authorizations
PO Box 419069
Rancho Cordova, CA 95741-9069
For more information about coverage determinations, exceptions and prior authorization, refer to the section, Your Part D prescription drugs: How to ask for a coverage decision or make an appeal, in your Evidence of Coverage (EOC).
- Member Medicare Part D Coverage Determination Request Form (pdf)
- Member Medicare Part D Redetermination Request Form
- Medicare Hospice Form (pdf)
- Link to the Centers for Medicare and Medicaid Services (CMS) Request for Medicare Prescription Drug Determination Form (for use by enrollees).
A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.
You can ask us to cover:
- a drug that is not on our list of drugs.
- a drug that requires prior approval.
- a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).
- a higher quantity or dose of a drug.
You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.
Generally, we will only approve your request for an exception if the alternative drug is included on our formulary, the lower cost-sharing drug or additional restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.You also can contact Member Services.
Standard and Fast Decisions
If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This applies only to requests for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.
If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.
After we make a decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.
If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Redetermination form, but you are not required to use it. You can send the form, or other written request, by mail or fax to:
Attn: Appeals and Grievances Dept.
P. O. Box 10450
Van Nuys, CA 91410-0450
Expedited appeal requests can be made by phone at 1-888-445-8913.
If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor’s supporting statement for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.
- Medicare Hospice Form (pdf)
- Center for Medicare and Medicaid Servoces(CMS) Request for Medicare Prescription Drug Determination Form( for use by enrollees)
For more information about coverage determinations and redeterminations refer to your Evidence of Coverage (EOC).