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Coverage Explanation

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Ancillary

Prescription medications are covered under Health Net Medicare Advantage with Prescription Drug (MA-PD) Ruby and Violet plans. Pharmacy coverage is indicated on the member's identification card. All covered prescriptions are listed on Health Net's Medicare Part D Formulary. Some medications may require prior authorization by Health Net.

Health Net individual MA-PD members have coverage up to their coverage limit. The prescription medication dollar limit is combined for brand-name and generic medications. Once a member reaches the coverage limit, the member has to pay full price. It is always in members' best interests to obtain a generic medication when possible to help keep them from reaching the coverage limit. Some members may have unlimited generic prescription medication coverage through the coverage gap.

Coverage for Immunosuppressive Medications

Immunosuppressive medications are covered following a Medicare-covered transplant. This is a basic benefit for all Health Net Medicare Advantage (MA) members whether or not they have a pharmacy benefit.

The member pays a plan-specific coinsurance for immunosuppressants following a covered transplant.

Exclusions and Limitations

The following list of exclusions and limitations (may vary depending on the member's specific benefits) applies to the Health Net Prescription Drug Program as listed in the subscriber's Evidence of Coverage (EOC):

  • Medications prescribed by a physician who is not participating with Health Net are not covered except when the physician's services have been authorized because of a medical emergency or the physician is the authorized referring physician.
  • Medications dispensed by non-participating pharmacies are not covered, except as specified in the EOC.
  • Any medication other than insulin and diabetic supplies that can be purchased without a prescription order over-the-counter is not covered, even if a physician writes a prescription for it.
  • Non-prescription contraceptive supplies and devices are not covered.
  • Oxygen is not covered.
  • Medications prescribed for cosmetic purposes - medications that are prescribed to enhance appearance, including those intended to treat wrinkles or hair loss, are not covered.
  • Appetite suppressants or medications used for weight control are not covered, unless for morbidly obese members whose only alternative is surgery (prior authorization required).
  • Biological sera, blood, blood derivatives, and blood plasma are not covered.
  • Allergy serum to lessen or end allergic reactions are not covered.

Medications prescribed for indications not approved by the Food and Drug Administration (FDA) are not covered unless:

  • The medication is prescribed by a participating provider for the treatment of a life-threatening condition.
    • The medication has been recognized for the treatment of that condition by one of the following:
      • The American Hospital Formulary Service (AHFS) Drug Information; or
      • One of the following compendia, if recognized by the federal Centers for Medicare & Medicaid Services as part of an anticancer therapeutic regimen:
        • The Elsevier Gold Standard's Clinical Pharmacology.
        • The National Comprehensive Cancer Network Drug and Biologics Compendium.
        • The Thomson Micromedex DrugDex.
      • Two articles from major peer-reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective, unless there is clear and convincing contradictory evidence presented in a major peer-reviewed medical journal.
    • The medication is prescribed by a participating provider for a chronic and seriously debilitating condition, the medication is medically necessary to treat that condition, and the medication is on Health Net's Medicare Part D Formulary.

It is the responsibility of the participating provider to submit to Health Net documentation supporting compliance with these requirements.

  • Hypodermic syringes and needles are not covered except for insulin needles and syringes.
  • Unit individual doses of medication dispensed in plastic or foil packages are not covered unless the packaging is FDA-required.
  • Lost, stolen or damaged medications are not covered. The member must pay the retail price to replace them.
  • FDA supply amounts for any number of days that exceed the FDA's or Health Net's indicated use recommendations are not covered.
  • Prescription medications covered elsewhere in the subscriber's EOC are not covered by the pharmacy benefit.
  • Medications prescribed for sexual dysfunction, including medications that establish, maintain or enhance sexual function or satisfaction, are not covered.
  • Medical supplies irrigation solutions, durable medical equipment (DME) and blood glucose monitoring supplies are not covered under the pharmacy benefit for Health Net MA plan members. Blood glucose test strips and lancets are covered under the Health Net MA member's DME benefit.
  • Nutritional supplements and homeopathic medications or vitamins, except prenatal and children's vitamins with fluoride, are not covered.

Part D is the prescription drug program added to Medicare by the Medicare Modernization Act of 2003 (MMA). It covers a portion of prescription medication costs not historically covered by Medicare. Medicare Advantage Part D (MA-PD) is available to members with Medicare Parts A and B.

Members who do not want Medicare prescription medication coverage may voluntarily opt-out of the MA-PD plan in which they are auto-enrolled and, instead, enroll in one of Health Net's Medicare Advantage (MA)-only plans that do not include prescription medication coverage. Health Net offers MA-PD and MA-only plans for MA members so that members can choose the plan that best fits their needs.

When considering health care options, beneficiaries have the choice of enrolling in a Health Net MA-PD plan that covers all Medicare benefits, including health care services and prescription medications. Under this scenario, members surrender coverage under Medicare and access all health care services through Health Net. Members must follow plan guidelines and access all services, including medical and prescription medication coverage, through Health Net's participating providers. This option provides beneficiaries with maximum cost savings. Medicare prescription drug program pricing for MA-PD is integrated with medical plan pricing.

Health Net participating prescribers and Health Net participating pharmacies are responsible for following the Health Net Medicare Part D Formulary. If a prescribed medication is not on the applicable formulary, the pharmacist should call the prescriber to request a change to a formulary medication, if appropriate. If the prescriber does not change to a recommended medication due to medical necessity, or one is not available, the prescriber is required to request prior authorization via CoverMyMeds® as described below, or by calling or faxing Health Net's pharmacy benefit manager (PBM), to request prior authorization and provide the medical necessity for the non-formulary medication.

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.

The request must document the medical necessity and specify which formulary medications have failed or why the member cannot use a medication on the Medicare Part D Formulary. If approved, the physician receives a faxed authorization that ensures the medication is covered under the member's pharmacy benefit. The pharmacist dispenses the approved medication and charges the member the applicable copayment. Members who have non-Medicare Part D Formulary coverage may receive a medication not on the Medicare Part D Formulary at a significantly higher copayment.

Some Health Net Medicare Advantage (MA) members in specific counties are only eligible for medications that are available generically and on the Medicare Part D Formulary. Even if there are no generics for treating the member's condition, brand-name medications are not covered. Brand-name medications processed through the Health Net claims processor are adjudicated at the Health Net contracting rate with the pharmacy.

A prescription mail-order program is available to Health Net members. Members are required to pay their mail-order copayments for up to a 90-day supply of medication depending on their plan. The member copayment applies to a 90-consecutive-calendar-day supply of maintenance medications (prescription medications used to manage chronic or long-term conditions when members respond positively to medication treatment and dosage adjustments are either no longer required or made infrequently) and each refill allowed by that order when prescribed by a Health Net participating physician or an authorized specialist. The 90-day-supply maximum is subject to the physician's judgment, the Food and Drug Administration (FDA) and Health Net's recommendations for use. In cases where a 90-day supply is not recommended by the FDA, the prescriber or Health Net, the mail order pharmacy dispenses the correct quantity. Prescriptions filled through the mail-order program should be written for a 90-day supply whenever possible.

For commercial [non-Individual and Family Plan (IFP)] members, new prescription medication requests may be mailed by the member to the mail order pharmacy or faxed by the prescribing physician. The member's Health Net identification number, date of birth, telephone number including area code, and Health Net should appear on the prescription request to ensure it is processed correctly. If available, a generic equivalent medication is automatically substituted unless the prescriber indicates DAW (dispense as written) or DNS (do not substitute). Members are charged a higher copayment.

For IFP and Cal MediConnect members, new prescription medication requests may be mailed by the member per the member's choice to either mail order pharmacy: CVS Caremark or Homescripts Pharmacy, or faxed to the mail order pharmacy of the member's choice by the prescribing physician.

Prior authorization is needed for prescription medication when:

  • A medication is listed on the Health Net Medicare Part D Formulary as needing prior authorization or a formulary restriction or limitation is exceeded.
  • A medication is not listed on the Medicare Part D Formulary.

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.

Urgent (expedited) coverage determinations for Part D medications are processed as expeditiously as the member's health condition requires but no later than the required time frame (24 hours).

Non-urgent (standard) coverage determination for Part D medications are processed as expeditiously as the member's health condition requires but no later than the required time frame (72 hours).

Faxes are accepted 24 hours a day and each request is tracked to ensure efficient handling of the request.

Prior authorization request forms are available through Health Net's pharmacy benefit manager (PBM) fax-back system; select option 1.

If a prescriber is requesting an exception to the Medicare Part D Formulary or an exception to a utilization management restriction, a written or oral supporting statement is required to indicate that the requested prescription medication should be approved because the alternative medication would not be as effective or would have adverse effects.

The Health Net Recommended Drug List (RDL) and Medicare Part D Formulary are the approved lists of covered medications. In addition, they identify whether a generic version of a brand-name medication exists and whether prior authorization is required.

Medications that are listed in the RDL and Medicare Part D Formulary are covered if the member has a prescription benefit plan; however, the prescription medication must be dispensed for a condition, illness or injury that is covered by Health Net. Some medications may require prior authorization from Health Net in order to be covered.

The Health Net RDL and Medicare Part D Formulary are available for review or download from the provider portal:

Last Updated: 05/05/2020