Prior Authorization Process
- Participating Physician Groups (PPG)
(does not apply to HSP)
Prior authorization is needed for prescription medications when:
- A medication is listed on the Health Net Recommended Drug List (RDL) as needing prior authorization.
- A medication is not listed on the RDL.
CoverMyMeds® is Health Net's preferred way to receive prior authorization requests. Visit the CoverMyMeds website 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.
Prior authorization requests must be electronically submitted, faxed to Health Net's pharmacy benefit manager (PBM) or submitted by any reasonable means of transmission. Faxes are accepted 24 hours a day, and each request is tracked to ensure efficient handling of inquiries from physicians and members. Requests for prior authorization may also be called into Health Net's PBM. Requests are processed within 24 hours for urgent requests and 72 hours for standard requests.
Health Net will respond via fax to advise providers the status of the request.
The Prescription Drug Prior Authorization Form (PDF) and medication-use guidelines are also available through the Pharmacy Service Center fax-back system: select option 2, for commercial claim form.
Exigent circumstances take place when a member is suffering from a serious health condition that may jeopardize their life, health or ability to regain maximum functions, or is undergoing a current course of treatment using a non-formulary medication.
Providers may request an expedited medication review based on exigent circumstances by contacting Health Net's PBM. The request must include an oral or written statement, which includes the following:
- An exigency exists and the basis for the exigency.
- A justification supporting the need for the non-formulary medication to treat the member's condition, including a statement that covered formulary medications on any tier would not be as effective as the non-formulary medication, or would have adverse effects.
Health Net makes a coverage determination and notifies the member and prescribing physician or other prescriber, as appropriate, of the determination no later than 24 hours after receiving the request or any additional information requested by Health Net that is reasonably necessary to make the determination. If approved, Health Net continues to provide the requested medication throughout the duration of the member's health condition.