Some covered drugs require prior authorization or have coverage restrictions or limits. This means that you must receive approval from Ambetter from Health Net before the drug will be covered. If your doctor or pharmacist tells you that a prescription drug is not covered, or has coverage restrictions or limits, your doctor may request prior authorization or an exception.
If your drug requires prior authorization, talk to your doctor about other drugs for your condition that are on our drug list. If there are no other drugs, your doctor may request prior authorization for your drug from Ambetter from Health Net.
For some drugs, we only cover a specific amount of the drug. If a drug has a quantity limit, your doctor must request prior authorization for a higher amount to be covered.
Yes. If your prescription is due while you're on vacation and you or your pharmacy let us know, we will cover an early refill. The refill may be limited to a one-month supply.
A compounded drug is made by a pharmacist because the manufacturer does not make it in a certain strength or with certain ingredients. These prescriptions require prior authorization. Please contact us for questions about compounded drug coverage.
Our drug list, or formulary, is a list of covered drugs selected by Health Net, along with a team of health care providers. These drugs are selected because they are believed to be a necessary part of a quality treatment program. Our drug lists are updated regularly and are subject to change. There is no guarantee that any specific drug included on the drug list will be prescribed for a particular medical condition.
Your pharmacy benefit covers insulin, lancets, needles, syringes, and blood glucose test strips. Specific manufacturers may be required. Please review the Formulary for covered products. Although these items are available over-the-counter, you must have a prescription for the pharmacy to process the claim.