Need quick access to our drug lists and pharmacy forms? You're in the right place. Here, you can find the most current information on drug coverage for both Medicare and commercial plans. Download Prior Authorization and other related forms at your convenience. Check the Pharmacist Resource Center for regular updates on changes in coverage and other pharmacy-related news.
Our Pharmacist Resource Center links pharmacists to important information about our prescription drug plans and our latest pharmacy updates.
Our formularies or drug lists include covered drugs that are selected by Health Net pharmacists, along with a team of health care providers. These drugs are chosen because they are believed to be a necessary part of a quality treatment program.
Need to see a particular member's drug list?
Our drug lists are selected by Health Net, along with a team of health care providers. These drugs are included because they are believed to be a key part of a quality treatment program. The drug lists are updated regularly and may change.
Please contact us if you need help finding the drug list that applies to your plan.
(for On/Off Exchange, Individual and Small Group Plans)
Our drug lists or formularies include a comprehensive list of covered drugs selected by Health Net, along with a team of health care providers. These drugs are selected because they are believed to be a necessary part of a quality treatment program. Our drug lists are updated regularly and are subject to change.
Published as a component of California's Medi-Cal Drug Use Review (DUR) Program by the Department of Health Care Services (DHCS), the purpose of the DUR educational articles is to alert and educate pharmacists and prescribers on clinically important drug therapy issues and potentially unsafe practices identified during a review of outpatient drug prescribing patterns.
For some drugs, your doctor must get approval from us before you fill your prescription. This is called prior authorization. We may not cover the drug if you don't get approval.
To request prior authorization, your prescriber must complete a Prior Authorization Form (PDF) and fax it to 866-399-0929.
Once we receive the request, we will review it to see if it can be approved. If we deny the request, we will tell you why it was denied. We will also tell you how to appeal the decision.
Your pharmacy benefit is administered by Medi-Cal Rx, and they are responsible for your authorizations.
To request prior authorization, your prescriber must complete a Prior Authorization Form and fax it to 800-869-4325.
If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, members or providers may request a coverage determination.
Members or providers can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested. An exception can be requested to:
Generally, Health Net will only approve a request for an exception if preferred alternative drugs or utilization restrictions would not be as effective in treating the member's condition and/or would cause the members to have harmful medical effects.
Some drugs require prior authorization. This means that members 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.
To request an exception or to obtain prior authorization, members or prescribers can email, fax or mail a coverage determination request to the contact information listed below. A coverage determination can also be requested by calling Customer Service. If a request is sent by email, it must include the member's name, Health Net member ID number and telephone number, as well as the details of the request. We also require a supporting statement from the prescriber explaining why a particular drug is medically necessary for the member's 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 (24 hours for Medi-Cal covered drugs) after we have received the prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the request, members 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 the member's health or their ability to function, members or their prescribers 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 members have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. Requests for a fast decision can be made by fax or by calling Customer Service. We will make our decision and respond to all requests as quickly as the member's health condition requires.
Calls received after hours will be handled by our automated phone system and a Health Net representative will return the call on the next business day.
To protect personal health information and privacy, please do not send emails to Health Net using a personal email account. Health Net has a Secure Messaging Center to make corresponding with us safe and efficient. To access Secure Messaging, you must be registered on HealthNet.com.
Health Net Prior Authorization Department
PO Box 419069
Rancho Cordova, CA 95741-9069
For more information about coverage determinations, exceptions and prior authorization, refer to the plan's coverage documents or call Customer Service. The fact that a drug is listed on the formulary does not guarantee that it will be prescribed for a particular medical condition.
Health Net* has partnered with Coram ® CVS Specialty™ Infusion Services as the designated preferred provider for site of care optimization for therapeutic infusions (SCOTI). Members have the option to transition infusions from the hospital to the home and an ambulatory infusion suite (AIS) located in the Ontario and San Diego facilities. Alternate site of infusion care is part of a member's standard benefit. The Plan has options available for members who are being treated with any of the infusion products listed in the table below.
| Disorder | Product |
|---|---|
| Alpha-1 Antitrypsin Deficiency | Aralast™ NP, Glassia ® , Zemaira ® |
| Amyloidosis | Onpattro ® |
| Asthma | Cinqair ® , Fasenra ® , Nucala ® , Xolair ® |
| Autoimmune Disorders | Actemra ® , Avsola™, Entyvio ® , Inflectra ® , Orencia ® , Remicade ® 1 , Renflexis ® , Simponi Aria ® |
| Hereditary Angioedema | Cinryze ® |
| Immune Deficiencies and Related disorders | Asceniv ® , Bivigam ® , Carimune ® , Cuvitru ® , Flebogamma ® , Gammagard ® Liquid, Gammagard ® S/D, Gammaked™, Gammaplex ®, Gamunex ® -C, Hizentra ® , Hyqvia ® , Octagam ® , Panzyga ® , Privigen ® , Xembify ® |
| Lysosomal Storage disorders | Aldurazyme ® , Cerezyme ® , Elaprase ® , Elelyso ® , Fabrazyme ® , Kanuma ® , Lumizyme ® , Naglazyme ® , Vimizim ® , Vpriv ® |
| Movement disorders | Radicava ® |
| Multiple Sclerosis 2 | Ocrevus ® (maintenance dose) |
| Ocular Disorders | Tepezza ® |
| Paroxysmal Nocturnal Hemoglobinuria | Soliris ® , Ultomiris ® |
| Rare Disorders | Crysvita ® |
| Sickle Cell Disease | Adakveo ® |
| Systemic Lupus Erythematosus | Benlysta ® |
1 Health Net prefers these biosimilar products over Remicade ® : Inflectra ® (infliximab-dyyb), Renflexis ® (infliximab-abda)
2 First dose of Ocrevus is infused in the Ontario and San Diego locations. Other multiple sclerosis agents, such as Lemtrada and Tysabri, are also eligible for alternative site of infusion care in the Ontario and San Diego locations.
Home infusion services are a covered benefit for Commercial and Exchange members. Use of the SCOTI program depends on whether Health Net or the member's assigned participating physician group (PPG) is financially responsible for the service.
PPGs should consult the Health Net Injectable Medication HCPCS/DOFR Crosswalk to determine the DOFR categorization of medications to determine the financial responsibility. The intent of the DOFR category of Home Health is to include only those medications in the crosswalk with the Home Health Infusion category.
For patient referrals or additional information, contact Health Net Pharmacy Team Mailbox at pharmsvs@centene.com and reference the SCOTI Program.
Last revised: March 2023