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Prescription Utilization Review

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

Prescription utilization is examined in aggregate monthly and quarterly to determine the types of medications that primary care physicians (PCPs) and specialists prescribe to members. Review of the prior authorization process for medications, formulary additions and use of generic medications, and review of medications for California Children's Services (CCS)-eligible conditions are conducted monthly with Health Net's pharmacy benefit manager (PBM), and Health Net Medi-Cal medical directors.

Potential cases of abuse are brought to the attention of the Health Net Program Integrity Department for investigation. The Health Net Public Programs Quality Improvement (PPQI) Department also conducts peer reviews or takes any other actions deemed necessary.

Plan-Specific Review

Prescription utilization for the health plan is analyzed quarterly by Health Net's Pharmacy and Therapeutics (P&T) Committee.

Utilization is separated by geographical area to address potential differences in practice patterns and for comparison purposes.

Pharmacy representatives participate in all aspects of utilization review that pertain to medications, including input from:

  • Pharmacy and Therapeutics Advisory Board.
  • Medical management.
  • Health Net Quality Improvement Committee (HNQIC).
  • Specially designed studies as requested by these committees or as deemed necessary by the health plan or by Health Net PBM.
Last Updated: 08/06/2021