When certain designated injectables are requested by a participating provider or physician group (PPG) that participates in a shared-risk arrangement, or when the financial risk belongs to Health Net, prior authorization must be obtained through Pharmacy Services. This requirement also applies to PPGs with delegated utilization management (UM). The only injectable medications that require prior authorization are self-injectable medications and a few specific injectable medications.

Some injectables (i.e., self-injectables) are excluded from Health Net's coverage responsibilities when used in the treatment of Medi-Cal members enrolled in carve-out programs, such as Medi-Cal Rx, California Children's Services (CCS) or the HIV/AIDS waiver program. Other injectables are excluded when a Medi-Cal member has a waiver program-eligible condition for which the member is disenrolled from Health Net (for example, most major organ transplants for adult members). For additional information regarding injectable medications, refer to the Health Net Injectable Medication HCPCS/DOFR Crosswalk (PDF) table.

When using the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (PDF) the participating provider or PPG must complete a Prior Authorization Request form detailing the medical necessity and the duration of the requested medication. The completed form must be faxed to Pharmacy Services. The participating provider or PPG may call Pharmacy Services directly for urgent requests.

The approval or request for additional information is faxed back to the original requester. Upon approval, Pharmacy Services forwards the approved authorization to one of Health Net's participating specialty pharmacy providers. The specialty provider contacts the Health Net member to arrange for delivery.