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Accessing Part D Prescription Medications

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Members enrolled in a Health Net Medicare Advantage Part D prescription drug (MA-PD) plan can access prescription medication benefits through a Health Net participating pharmacy within their service area. For the highest level of benefits, members must ensure the prescription medication is listed on the Health Net Medicare Part D Formulary. Members may get prescription medications from out-of-network pharmacies under certain conditions.

Part D Prescription Medication Coverage

The Health Net Provider Participation Agreement (PPA) does not cover Medicare Part D benefits.

Part D coverage includes the following when listed in the Medicare Part D Formulary:

  • Infusion medications in the home that can be given intravenously, either by gravity or by a disposable (non-durable) pump without the precision of regulating the flow with a DME infusion pump.
  • Inhaled medications through a metered dose inhaler.
  • Vaccines previously not covered under Part B may be eligible for coverage under Part D.
  • Self-administered medications, if self-administered by more than 50 percent of Medicare beneficiaries, as determined by Medicare.

Coverage of some Part D medications is subject to medical necessity review by the Health Net's pharmacy benefit manager (PBM). See the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov for the common Part D vaccines covered under Medicare.

Part D Prescriber Requirements

In accordance with the CMS, 42 CFR 423.120(c)(6), Health Net providers who prescribe Part D medications for Medicare members must be enrolled in Medicare in an approved status, or have a valid opt-out affidavit on file, for medications they prescribe to be covered under Part D. Refer to the CMS website to view the Part D Prescriber Enrollment Fact Sheet

Providers who are currently enrolled in Medicare in an approved status, or have a valid opt-out affidavit on file, should confirm their revalidation status due date on the CMS website at https://data.cms.gov/revalidation as soon as possible to avoid a lapse in their Medicare status. The list provides expiration dates up to six months.

Part D Prior Authorization Coverage Determination Requests

In accordance with CMS regulations, the prescriber or member may initiate a prior authorization request for any prescription medication that requires prior authorization.

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, fax the completed form to the number listed on the form.

Prescription medication prior authorization requests by a prescriber can be submitted by telephone or faxed to Health Net's PBM. Members must contact the appropriate Health Net Member Services Department to request prior authorization. Prior authorization request turnaround times are as follows:

  • Standard request is 72 hours.
  • Expedited request is 24 hours.

Once a decision is rendered (denial or approval), a notification is faxed to the prescriber or pharmacy. The member is notified of the decision in writing and by telephone.

Billing Health Net's PBM for Vaccines

Providers may bill directly to Health Net PBM for Medicare Part D vaccines and their administration using the CMS-1500 form.

Billing the Member

Providers may bill the member for the entire vaccine charge, including the Part D vaccine and administration fee. The member must subsequently submit a paper claim to Health Net for reimbursement. Health Net only reimburses the member Health Net's allowable costs for both the vaccine and the administration. If a prescriber bills a member in excess of Health Net's allowable costs, the additional cost is the member's responsibility.

Submitting a Claim for Vaccines Online

Providers may submit a claim online for the costs of the vaccine and the administration via the TransactRx™ Medicare Part D Vaccine Manager.

Last Updated: 05/05/2020