Prior Authorization, Step Therapy and Quantity Limits
Health Net had a team of doctors and pharmacists create tools to help us provide quality coverage to our members. The tools include‚ but are not limited to: prior authorization and step therapy criteria‚ clinical edits and quantity limits. Some examples include:
- Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
- Quantity Limits: For certain drugs, Health Net limits the amount of the drug we will cover per prescription or for a defined period of time.
- Prior Authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, Health Net may not cover the drug. Prior Authorization Criteria
- Step Therapy: For certain drugs, we require you to try a less expensive alternative before “stepping up” to drugs that cost more. Step Therapy Criteria Step Therapy Criteria - English (pdf) | EStep Therapy Criteria - Español (pdf)
You can ask Health Net to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to the Comprehensive Formulary. When you are requesting a utilization restriction exception you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination* form that is provided below. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.
You can contact Member Services at any time for the most recent list of covered drugs.
Our plan has a team of doctors and pharmacists who create tools to help us provide you quality coverage. Examples are:
- Prior Authorization: We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug.
- Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
- Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, one tablet per day. This may be in addition to a standard one-month or three-month supply.
- Age Limits: Some drugs require a prior authorization if your age does not meet drug manufacturer, Food and Drug Administration (FDA), or clinical recommendations.
Prior Authorization Criteria:
- Medicare Part D Pharmacy PA Criteria - English (PDF)
- Medicare Part D Pharmacy PA Criteria - Spanish (PDF)
Step Therapy Criteria:
- Refer to the List of Drugs (Formulary) for drug requirements and limits.
You can ask us to make an exception to our coverage rules. For specific types of exceptions, refer to the Evidence of Coverage or the Coverages Determinations and Redeterminations for Drugs page.
We must decide within 72 hours of getting your doctor’s supporting statement. You or your doctor can request a fast (expedited) exception if your health may be harmed by waiting. Your doctor must submit a supporting statement with the Coverage Determination Form. If we grant your request, we must give you a decision no later than 24 hours after we get your doctor’s supporting statement.
If you have questions or want to get the most recent list of drugs contact Member Services. We are here to help!