25-1197 Reminder: Prior Authorization Requirements for Outpatient Pharmaceuticals - Submitted Under Medical Benefit

Date: 11/12/25

Submit directly to Health Net Pharmacy Services to ensure timely medical claims payment and avoid denials

As a reminder, if Health Net on behalf of CalViva Health, has risk/shared risk, prior authorization (PA) requests for injectable medications that are on the Health Net Prior Authorization Requirements lists must be submitted directly to Health Net Pharmacy Services. Claims submitted without Health Net Pharmacy Services authorization will be denied. Participating physician group (PPG) authorizations will not be accepted for claims payment.

Required steps for submitting claims for injectable medications that require 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 Prior Authorization Requirements lists 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).

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 (see below).

4 Submit the claim after authorization approval.
Include all required documentation, including Health Net Pharmacy Services authorization approval.

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 and self-injectable medications	800-869-4325	800-977-2273 (Medi-Cal Rx)
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 and self-injectable medications	Physician-administered medications
Medi-Cal	800-977-2273 (Medi-Cal Rx)	800-867-6564 (option 2)

 

This information applies to Physicians and Hospitals.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.