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Prescription Drug Program

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Counties Covered

  • Fresno
  • Kern  
  • Kings
  • Los Angeles
  • Madera
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego 
  • San Joaquin
  • Stanislaus
  • Tulare

The following medications are covered under Health Net's Medi-Cal plan:

  • Medications administered while hospitalized or at a medical office or emergency room
  • Medications listed on the Health Net Medi-Cal Recommended Drug List (RDL) prescribed by a Health Net practitioner and filled at a participating pharmacy
  • Medications for mental health conditions prescribed by a psychiatrist that are on the Department of Health Care Services (DHCS) Medi-Cal List of Contract Drugs and filled at a contracting pharmacy, except those mental health medications excluded in the Exclusions and Limitations section of the member's Evidence of Coverage (EOC). Refer to the discussion of Carve-Out Medications below for more information
    • Mental health medications that are excluded from Health Net's coverage responsibilities are covered under the DHCS Medi-Cal fee-for-service (FFS) program
  • A 72-hour supply of a covered medication may be dispensed in a medical emergency

Medication coverage is limited to generic medications when a generic equivalent is available. The medication benefit is generally limited to a maximum 30-day supply of medication at any one time.

Most medications for the treatment of AIDS and HIV are excluded from Health Net's coverage responsibilities and are covered under the DHCS Medi-Cal FFS program. Refer to the discussion of Carve-Out Medications in this section for more information.

Health Net Medi-Cal does not cover health care services for California Children's Services (CCS)-eligible conditions, but they are covered under the CCS program. Prescriptions written for children with CCS active conditions need to be written by a CCS-paneled provider and billed directly to CCS.

Due to the passage of federal legislation (HR 3971), where federal financial contribution has been discontinued for all medications used to treat sexual or erectile dysfunction, the state of California has decided to discontinue coverage of such medications under the Medi-Cal program, unless used to treat a condition other than sexual or erectile dysfunction.

In Los Angeles County, providers affiliated with Molina Healthcare, a subcontracting health plan, must use Molina's medication formularies, and comply with their prior authorization requirements when prescribing medications to Health Net members linked through Molina. Contact the Molina Pharmacy Department for more information.

Generic Substitution

Generic substitution is mandatory. Prescriptions written for brand-name medications are filled with a generic-equivalent when one is available.

Over-The-Counter Medications

Health Net covers select over-the-counter (OTC) medications comparable to those listed in the Department of Health Care Services (DHCS) Medi-Cal List of Contract Drugs.

The Department of Health Care Services (DHCS) has carved out selected psychotherapeutic, coagulation factors, HIV-related medications and medications to treat alcohol or drug dependence from Health Net's coverage responsibilities. These medications are covered by the Medi-Cal fee-for-service (FFS) program. Pharmacies bill the state directly for these medications.

For a list of carved-out AIDS and HIV treatment medications, refer to the Excluded Medications for HIV and AIDS discussion in the AIDS Waiver Program section of the Public Health topic.

For a list of carved-out psychotherapeutic medications, refer to the Excluded Psychotherapeutic Medications discussion in the Mental Health section of the Public Health topic.

Health Net Medi-Cal does not cover health care services, including prescription medications, for California Children's Services (CCS)-eligible conditions, but they are covered under the CCS program. Prescriptions written for children with CCS-active conditions must be written by a CCS-paneled provider and billed directly to CCS.

Compounded Medications

Health Net covers medically necessary compounded prescriptions that meet all of the following conditions:

  • Includes at least one federal legend medication listed on the Health Net Medi-Cal Recommended Drug List (RDL) as one of its main compounded ingredients.
  • There is scientific evidence and peer-reviewed literature demonstrating safety and effectiveness for the specific medical condition.
  • There are no acceptable proprietary alternative medications. The compound must be within the Food and Drug Administration (FDA)-approved indications.
  • All compounded prescriptions require prior authorization through Health Net's pharmacy benefit manager (PBM).

Chemotherapy Medications

Health Net Medi-Cal covers all oral anti-neoplastic agents for FDA-approved indications. Prior authorization may be required to document diagnosis.

Health Net covers the following meters and test strips with a prescription from participating pharmacies:

  • Freestyle Lite®
  • Freestyle-Freedom Lite®
  • Freestyle InsuLinx®
  • Freestyle Precision-Neo®
  • Precision Xtra®

Test strips are available in packages of 50 or 100 and may be prescribed in multiples of 50 or 100, sufficient to provide up to a 30-day supply. No other meters or test strips are covered without prior approval for medical necessity.

Members have coverage for diabetic supplies under their pharmacy benefit. Insulin-dependent and non-insulin-dependent diabetics are eligible for blood glucose monitoring supplies.

The Health Net Medi-Cal Recommended Drug List (RDL) was developed to help physicians, pharmacists and other health care providers evaluate the various available medication products. The Medi-Cal RDL is maintained by Health Net's Pharmacy and Therapeutics (P&T) Committee. The P&T Committee, which consists of participating primary care and specialty physicians and pharmacists, evaluates the safety profile and effectiveness of the medications. The medications listed are selected from the Food and Drug Administration (FDA)-approved medications and are reviewed by the committee. The Medi-Cal RDL is continually reviewed and revised in response to recommendations from participating providers and as new clinical data and medication products become available.

The Health Net Medi-Cal RDL provides a comprehensive selection across therapeutic classes. Unlike the state Medi-Cal List of Contract Drugs, the Health Net Medi-Cal RDL does not limit prescriptions to six per month. In addition, select over-the-counter (OTC) medications comparable to those approved by the California Department of Health Care Services (DHCS) are covered on the Health Net Medi-Cal RDL, and generic medications are not limited to selected manufacturers.

Health Net welcomes physicians' comments and recommendations on the Health Net Medi-Cal RDL. Providers should send or fax recommendations and questions to Health Net's pharmacy benefit manager (PBM).

In Los Angeles County, practitioners affiliated with Molina Healthcare, a subcontracting health plan, must use Molina's medication formularies when prescribing medications to Health Net members affiliated through Molina.

The Health Net Medi-Cal RDL is available on Health Net's provider portal, located under Pharmacy Information > Drug Information for California State Health Programs. To request paper copies of the Medi-Cal RDL, contact the Health Net National Provider Communications Department.

Medications Not Listed on the Medi-Cal Recommended Drug List

Providers must use the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (PDF) to request medications not listed on the Health Net Medi-Cal RDL if Medi-Cal RDL alternatives have been tried without success or are contraindicated.

Certain medications on the Health Net Medi-Cal Recommended Drug List (RDL) require prior authorization for coverage.

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:

  1. Submit the prior authorization electronically through the CoverMyMeds website.
  2. Complete and submit the prior authorization form online through the Envolve Pharmacy Solutions website.
  3. 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.

Health Net will respond via fax to advise providers the status of the request. Physicians and pharmacies receive a notification of decision within 24 hours if all the required information is provided on the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (PDF). Requests may be electronically submitted, faxed to Health Net's pharmacy benefit manager (PBM), or submitted by any reasonable means of transmission.

Medications not on the list may be requested using the prior authorization process if alternatives on the Health Net Medi-Cal RDL have been tried without success or are contraindicated. The Health Net Medi-Cal RDL is available electronically on the provider portal of the Health Net website at provider.healthnet.com. To request a copy of the Health Net Medi-Cal RDL, contact the Health Net National Provider Communications Department. In Los Angeles County, practitioners affiliated with Molina Healthcare, a subcontracting health plan, must use Molina's medication formularies and comply with its prior authorization requirements when prescribing medications to Health Net members linked through Molina. Contact the Molina Pharmacy Department for more information.

The following document applies only to Physicians and Participating Physician Groups (PPGs) and these counties: Fresno, Kern, Kings, Los Angeles, Madera, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, Tulare.

Participating physician groups (PPGs) and physicians contracting directly with PPGs that do not have responsibility for injectable medications must submit an authorization request to Health Net. The Health Net Medi-Cal Recommended Drug List (RDL) is available on Health Net's provider portal located under Pharmacy Information > Drug Information for California State Health Programs for more information about medications.

Any services related to California Children's Services (CCS)-eligible medical conditions must be approved by the CCS program. Refer to the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS, Chapter 4, Medical Eligibility, Article 4 .

Members who require antihemophilic factors must be approved by the Department of Health Care Services (DHCS) treatment authorization request (TAR) process.

Medications prescribed as an aid to weight loss may be covered with prior authorization from Health Net's pharmacy benefit manager (PBM). Prior authorization requests must document a structured care plan for the member that includes dietary counseling, including caloric intake, a structured exercise program and active regular follow-up to assess progress and compliance. Requests must be made using the Prescription Drug Prior Authorization form (PDF).

The initial authorization could be from one month to six months depending on the product and supporting documentation. Authorization of subsequent prescriptions requires documentation of member compliance with the structured care plan and weight loss during the initial trial in which the prescription was authorized.

Nutritional supplements and replacements are a conditional benefit for Health Net's Medi-Cal members and may be covered subject to prior authorization.

Health Net's pharmacy benefit manager (PBM) authorizes a one-time override for a 14-day supply of the requested formula for members ages 12 months and younger who have not previously had a prior authorization for formula. Depending on capitation status, the request is then forwarded to the Health Net Medi-Cal Health Services Department or to the appropriate participating physician group (PPG) to facilitate further prior authorization.

Special infant formula requests for members with conditions that make them eligible for services through public health carve-out programs must be referred to the public health program agencies. Such carve-out programs include California Children's Services (CCS) and Genetically-Handicapped Persons Program (GHPP).

In Los Angeles County, practitioners affiliated with Molina Healthcare, a subcontracting health plan, must follow Molina's prior authorization requirements when requesting special infant formulas for Health Net members assigned to Molina Healthcare. Contact the Molina Pharmacy Department for more information.

Last Updated: 11/19/2021