CommercialPrior AuthHigh impact
25-1196 Reminder: Prior Authorization Requirements for Outpatient Pharmaceuticals - Submitted Under Medical Benefit
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net now requires all prior authorization requests for injectable medications to be submitted directly to Health Net Pharmacy Services when Health Net has risk/shared risk arrangements. Participating physician group authorizations will no longer be accepted, and claims submitted without proper Health Net Pharmacy Services authorization will be denied.
Action Required
Immediately: Billing team must update prior authorization workflow for all injectable medications. Before submitting claims: 1) Verify if injectable requires PA by checking Health Net Prior Authorization Requirements lists, 2) Use only form 61-211 (Prescription Drug Prior Authorization or Step Therapy Exception Request Form), 3) Submit PA requests directly to Health Net Pharmacy Services using appropriate fax/phone numbers based on member's plan type (Commercial, Medi-Cal, or Medicare), 4) Wait for authorization approval before submitting claims. Update staff training to ensure physician group authorizations are no longer used. Claims without proper Health Net Pharmacy Services authorization will be denied.