CommercialPrior AuthHigh impact
25-1127 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 is changing prior authorization submission process for injectable medications. All PA requests for injectables on the Health Net Pre-Certification Drug List must now be submitted directly to Health Net Pharmacy Services instead of through Participating Physician Groups (PPGs).
Action Required
Before January 1, 2026: Billing team must update prior authorization workflow for Health Net injectable medications. 1) Verify all injectable medications against Health Net Pre-Certification Drug List before treatment. 2) Use only Form 61-211 for PA requests - update forms library and train staff. 3) Submit PA requests directly to Health Net Pharmacy Services using correct fax/phone numbers by member type (Commercial: 800-314-6223, Medi-Cal: varies by medication type, Medicare: 800-977-8226). 4) Update billing system to require Health Net Pharmacy Services authorization number on all injectable claims. Claims submitted without proper Health Net Pharmacy Services authorization will be denied - PPG authorizations no longer accepted.