MedicaidPrior AuthHigh impact
25-1128 Prior Authorization Requirements for Outpatient Pharmaceuticals - Submitted Under Medical Benefit
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Effective January 1, 2026, Health Net/CalViva Health requires all prior authorization requests for injectable medications to be submitted directly to Health Net Pharmacy Services instead of through Participating Physician Groups. Claims submitted without Health Net Pharmacy Services authorization will be denied, and PPG authorizations will no longer be accepted.
Action Required
By January 1, 2026: Billing team must implement new prior authorization workflow for injectable medications. 1) Train staff to verify injectable medications against Health Net Pre-Certification Drug List before administration. 2) Use only Form 61-211 (Prescription Drug Prior Authorization or Step Therapy Exception Request Form) for PA requests. 3) Submit PA requests to Health Net Pharmacy Services via designated fax numbers (800-869-4325 for pharmacy/self-injectable, 833-953-3436 for physician-administered). 4) Update billing system to require Health Net Pharmacy Services authorization number before claim submission. 5) Stop accepting PPG authorizations for injectable medication claims. Claims without proper Health Net Pharmacy Services authorization will be denied.