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Coverage Determinations and Redeterminations for Drugs

A coverage determination is a decision about whether a drug prescribed for you will be covered by us and the amount you’ll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • a drug that is not on our list of drugs (formulary).
  • a drug that requires prior approval.
  • a drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).
  • a higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail or phone. You must include your doctor’s statement explaining why your drug is necessary for your condition. Within 72 hours after we receive your doctor’s statement, we must make our decision and respond. If we deny your request you can appeal our decision. Information on how to file an appeal will be included in the denial notice.

Generally, we will approve your request only if the alternative drug is on our list of drugs, or if a lower cost-sharing drug or added restrictions don’t treat your condition as well. The contact information is listed below. You also can contact Member Services.

You may use this form to submit your request:

To submit the Coverage Determination form online, please click here.

Phone:
Members: Contact Member Services
Doctors and Other Prescribers: 1-800-867-6564
TTY: 711

Fax:
1-800-977-8226

Mail:
Health Net
Attn: Prior Authorizations
PO Box 419069
Rancho Cordova, CA 95741

Standard and Fast Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This applies only to requests for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a decision, we send you a notice explaining our decision. The notice includes information on how to appeal a denied request.

Redeterminations

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for an appeal (redetermination). You have 60 days from the date of our denial notice to request a redetermination. You can complete the Request for Redetermination form, but you are not required to use it.

You can send the form or other written request by mail or fax to:

Fax: 
1-877-713-6189

Mail:  
Health Net
Attn: Appeals and Grievances Department
P.O. Box 10422
Van Nuys, CA 91410-0422

Other Forms


Information last updated: 07/11/2018
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