CommercialPrior AuthHigh impact
25-1198 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, not to participating physician groups (PPGs). Claims submitted without proper Health Net Pharmacy Services authorization will be denied.
Action Required
Immediately: Billing team must verify injectable medications on Health Net Prior Authorization Requirements lists before submitting claims. Use only Form 61-211 for PA requests. Submit all injectable medication PA requests directly to Health Net Pharmacy Services via fax (800-869-4325 for pharmacy/self-injectable, 833-953-3436 for physician-administered) or phone. Stop submitting PA requests to PPGs. Update workflow to obtain Health Net Pharmacy Services authorization approval before claim submission. Claims without proper authorization will be denied.