MedicaidPrior AuthHigh impact
25-1129 New 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 Community Health Plan of Imperial Valley is changing the prior authorization submission process for injectable medications. All PA requests for injectable medications on the Health Net Pre-Certification Drug List must now be submitted directly to Health Net Pharmacy Services using specific forms and contact methods, and PPG authorizations will no longer be accepted for claims payment.
Action Required
Before January 1, 2026: Billing team must implement new prior authorization workflow for injectable medications. 1) Update billing system to flag all injectable medications on Health Net Pre-Certification Drug List for PA verification. 2) Train staff to use only Form 61-211 (Prescription Drug Prior Authorization or Step Therapy Exception Request Form). 3) Update contact procedures to use new fax numbers: 800-869-4325 for pharmacy/self-injectable medications, 833-953-3436 for physician-administered medications. 4) Ensure all claims include Health Net Pharmacy Services authorization approval before submission. Claims submitted without proper Health Net Pharmacy Services authorization will be denied and PPG authorizations will not be accepted.