25-1129 New Prior Authorization Requirements for Outpatient Pharmaceuticals - Submitted Under Medical Benefit
Date: 10/24/25
Submit directly to Health Net Pharmacy Services to ensure timely medical claims payment and avoid denials
Effective January 1, 2026, Health Net on behalf of Community Health Plan of Imperial Valley, is changing the submission process for prior authorizations (PAs) for injectable medications. As outlined in your contract with Health Net, if your Participating Physician Group (PPG) is not delegated for pharmacy utilization management, you must now submit PA requests for injectable medications that are on the Health Net Pre-Certification Drug List directly to Health Net Pharmacy Services.
Based on the Division of Financial Responsibility (DOFR) and the Delegation Agreement, the PPG is not delegated for pharmacy utilization management, when the following statement applies:
“If Health Net has the risk and/or shared risk for such services, Health Net has the responsibility
to make the authorization determinations for pharmacy and injectable coverage. Requests
for such pharmaceuticals are to be submitted for Health Plan approval.”
Required steps for submitting claims for injectable medication requiring prior authorization
To ensure timely claims payment and avoid denials, please follow these steps:
1 Verify if injectable medication requires a PA review.
Confirm the injectable medication is listed on the Health Net Pre-Certification Drug List at Prior Authorizations. Select the applicable list based on the member’s line of business.
2 Complete the correct PA form.
Use the Prescription Drug Prior Authorization or Step Therapy Exception Request Form (No. 61-211).
- See attached.
- Download the form at Prescription Drug Prior Authorization or Step Therapy Exception Request Form (PDF).
Note: Submissions using incorrect forms will be denied.
3 Submit PA form to Health Net Pharmacy Services
Send the completed form using the appropriate contact method based on the member’s line of business (see below).
4 Submit the claim after authorization approval
- Include all required documentation, including Health Net Pharmacy Services authorization approval
- Claims submitted without the Health Net Pharmacy Services authorization will be denied
- PPG authorizations will not be accepted for claims payment.
Where to send prior authorization requests
Refer to the table below or visit the Health Net Pharmacy Services contact page.
Request type | Fax | Phone |
|---|---|---|
Pharmacy & self-injectable medications | 800-869-4325 | 800-977-2273 |
Physician-administered medications | 833-953-3436 | 800-867-6564 (option 2) |
Have questions?
Contact the applicable Health Net Pharmacy Services number below for assistance:
Request type | Pharmacy & Self-Injectable Medications | Physician-Administered Medications |
|---|---|---|
Medi-Cal | 800-977-2273 (Medi-Cal RX) | 800-867-6564 (option 2) |
This information applies to Participating Physician Groups (PPGs).
This information applies to Medi-Cal in Imperial County.