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.

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.

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

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

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.

There are three options for submitting a prior authorization 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 members with Medicare plans, D-SNP plans, Employer Group Waiver Plans (EGWPs) and on/off-exchange Ambetter HMO/PPO plans, the prescribing physician can send requests for new prescriptions via fax to Express Scripts® Pharmacy at 800-837-0959 or e-prescribe the request to Express Scripts Pharmacy. Members can request mail order service for prescription medications and refills from Express Scripts Pharmacy by phone, mail or online at express-scripts.com/rx.

Note: For Employer Group Retiree Drug Subsidy (RDS) members, use CVS Caremark mail order service.

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.

Prior authorization is needed for prescription medication when:

There are three options for submitting a prior authorization 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 Pharmacy Services 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.