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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.
Last Updated: 11/09/2022