Cal MediConnect Coverage Explanation

Provider Type

Participating Physician Groups (PPG)
Hospitals

Ancillary

Prescription medications are covered under Health Net's Cal MediConnect Part D plan. Pharmacy coverage is indicated on the member's identification card. All covered prescriptions are listed on Health Net's Cal MediConnect Formulary. Some medications may require prior authorization by Health Net's pharmacy benefit manager (PBM).

Coverage for Immunosuppressive Medications

Immunosuppressive medications for a Medicare-covered transplant are covered under Part B.

Coverage for Non-Prescription Medications

Select Centers for Medicare & Medicaid Services (CMS) Part D-excluded non-prescription (over-the-counter) medications are covered under Health Net's Cal MediConnect plan. Over-the-counter medications are only covered when appropriately dispensed on receipt of a legal prescription.

Exclusions and Limitations

The following exclusions and limitation apply to Health Net's Cal MediConnect Part D plan:

Medications dispensed by non-participating pharmacies may not be covered, except as specified in the member's Evidence of Coverage (EOC).
Only select over-the-counter medications are covered on the Cal MediConnect Formulary or through the prior authorization process when a prescriber writes a prescription for them.
Medications that can be purchased without a prescription over-the-counter are not covered even when a prescriber writes a prescription for it except when the medication is listed on Health Net's Cal MediConnect Formulary, or an exception for a non-formulary medication is granted.
Medications prescribed for cosmetic purposes - medications that are prescribed to enhance appearance, including those intended to treat wrinkles or hair loss, are not covered.
Medications prescribed for indications not approved by the Food and Drug Administration (FDA) are not covered unless:
- The medication has been recognized for the treatment of that condition by one of the following:
  - The American Hospital Formulary Service (AHFS) Drug Information
  - DRUGDEX Information System
  - One of the following compendia, if recognized by CMS as part of an anticancer therapeutic regimen:
    - The Elsevier Gold Standard's Clinical Pharmacology Compendium
    - The National Comprehensive Cancer Network Drug and Biologics Compendium
    - The Thomson Micromedex DrugDex Compendium
  - Two articles from major peer-reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective unless there is clear and convincing contradictory evidence presented in a major peer-reviewed medical journal.
- It is the responsibility of the participating prescriber to submit to Health Net documentation supporting compliance with these requirements.
Hypodermic syringes and needles are not covered except for insulin needles and syringes.
Lost, stolen or damaged medications are not covered. The member must pay the retail price to replace them.
Medications prescribed for sexual dysfunction, including medications that establish, maintain or enhance sexual function or satisfaction, are not covered.
Nutritional supplements and homeopathic medications or vitamins, except prenatal and children's vitamins with fluoride, are not covered.

Accessing Medi-Cal Covered Medications

Members enrolled in Health Net's Cal MediConnect plan can access medications in certain CMS-excluded medication categories that are covered by Medi-Cal through a Health Net network pharmacy. To obtain the highest level of benefits, members must ensure the medication is listed on the Health Net Cal MediConnect Formulary. Prior authorization is required for non-formulary medications. Members may obtain prescription medications from an out-of-network pharmacy under certain conditions.

Cal MediConnect Medi-Cal Medication Coverage

Coverage includes medications in the following categories when listed on the Health Net Cal MediConnect Formulary:

Anorexia, weight loss or weight gain
Certain vitamin and mineral products (excluding dietary supplementation)
Symptomatic relief of coughs and colds
Selected non-prescription medications (including nicotine products)

Covered products are comparable to the Medi-Cal Fee-for-Service (FFS) Contract Drug List. Non-prescription (over-the-counter) medications are only covered when the member presents a valid prescription at a Health Net network pharmacy.

Part D is the Medicare Advantage Prescription Drug program (MA-PD) added to Medicare by the Medicare Modernization Act (MMA) of 2003. It covers a portion of prescription medication costs not historically covered by Medicare. MA-PD is available to members with Medicare Parts A and B.

Health Net's Cal MediConnect Part D plan is an MA-PD plan that covers all Medicare benefits, including health care services and prescription medications. Under this scenario, members surrender coverage under Medicare and access all health care services through Health Net. Members must follow plan guidelines and access all services, including medical and prescription medication coverage, through Health Net's participating providers. This option provides members with maximum cost savings. Medicare prescription drug program pricing for MA-PD is integrated with medical plan pricing.

Members who do not want to be enrolled in Health Net's Cal MediConnect Part D plan may voluntarily opt-out of the Health Net Cal MediConnect Part D plan in which they are auto-enrolled.

Health Net participating prescribers and Health Net participating pharmacies are responsible for following the Health Net Cal MediConnect Formulary. If a prescribed medication is not on the applicable formulary, the pharmacist should call the prescriber to request a change to a formulary medication, if appropriate. If the prescriber does not change to a recommended medication due to medical necessity, or one is not available, the prescriber is required to request prior authorization via CoverMyMeds® as described below, or by calling or faxing Health Net's pharmacy benefit manager (PBM), to request prior authorization and provide the medical necessity for the non-formulary medication.

CoverMyMeds is Health Net's preferred way to receive prior authorization requests. Visit go.covermymeds.com/envolve to begin using this free service.

There are three options for submitting a prior authorization form:

Submit the prior authorization electronically through the CoverMyMeds website.
Complete and submit the prior authorization form online through the Envolve Pharmacy Solutions website.
Print the appropriate form found on the Health Net provider portal or in the portal's Provider Library under Forms. Once you have printed the form and completed all appropriate fields, please fax the completed form to the number listed on the form.

The request must document the medical necessity and specify which formulary medications have failed or why the member cannot use a medication on the Cal MediConnect Formulary. If approved, the physician receives a faxed authorization that ensures the medication is covered under the member's pharmacy benefit. The pharmacist dispenses the approved medication and charges the member the applicable copayment.

Brand-name medications processed through the Health Net claims processor are adjudicated at the Health Net contracting rate with the pharmacy.

Prior authorization is needed for prescription medication when:

A medication is listed on the Health Net Cal MediConnect Formulary as needing prior authorization or a formulary restriction or limitation is exceeded.
A medication is not listed on the Cal Medi Connect Formulary.

CoverMyMeds® is Health Net's preferred way to receive prior authorization requests. Visit go.covermymeds.com/envolve to begin using this free service.

There are three options for submitting a prior authorization form:

Submit the prior authorization electronically through the CoverMyMeds website.
Complete and submit the prior authorization form online through the Envolve Pharmacy Solutions website.
Print the appropriate form found on the Health Net provider portal or in the portal's Provider Library under Forms. Once you have printed the form and completed all appropriate fields, fax the completed form to the number listed on the form.

Urgent (expedited) coverage determinations for Part D medications are processed as expeditiously as the member's health condition requires but no later than the required time frame (24 hours).

Non-urgent (standard) coverage determination for Part D medications are processed as expeditiously as the member's health condition requires but no later than the required time frame (72 hours).

Faxes are accepted 24 hours a day and each request is tracked to ensure efficient handling of the request.

Prior authorization request forms are available through Health Net's pharmacy benefit manager (PBM) fax-back system; select option 1.

If a prescriber is requesting an exception to the Cal MediConnect Formulary or an exception to a utilization management restriction, a written or oral supporting statement is required to indicate that the requested prescription medication should be approved because the alternative medication would not be as effective or would have adverse effects.