MedicaidPrior AuthMedium impact
25-1169 Provider Guide: Accessing Therapeutic Infant Formula
Health Net·CA · Pediatrics, Family Medicine, General Practice·Prior Authorization
We identified it
Jun 20, 2026
Summary
Health Net Medi-Cal now requires prior authorization for all therapeutic infant formulas for infants under 12 months. The policy establishes specific authorization timelines (5 business days standard, 72 hours urgent) and procedures for inpatient, outpatient, and emergency situations.
Action Required
Immediately: Billing team must update systems to require prior authorization for all therapeutic infant formula claims for patients under 12 months. Providers must complete the Prescription Drug Prior Authorization or Step Therapy Exception Form and fax to 833-953-3436 for outpatient cases, or 833-963-3436 for inpatient discharge planning. Front desk staff should inform patients about the PA process and potential delays. Claims will be denied without proper prior authorization.