CurrentCentenePolicy N/A

AON Benefit Experience Drug List

This document is the Health Net AON Benefit Experience Drug List (formulary) describing covered prescription drugs, formulary tiers, utilization management (PA, QL, ST, LA, SP), limits, pharmacy access (network, specialty, mail order), prior authorization and exception/step-therapy processes, preventive drugs, and examples of drug listings and tier/limit notations. It covers member-facing and provider operational rules for pharmacy benefits.

Policy Summary

PayerCentene

PolicyAON Benefit Experience Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionPrescribers must request prior authorization for drugs listed with 'PA' via CoverMyMeds, phone or fax; Health Net must respond within required timeframes (72h standard, 24h expedited).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

MonthlyFormulary update frequency

PA, QL, ST, SP, LACommon utilization management

90 daysMail order max supply

$250Oral cancer max copay

manyEntries with QL/PA/ST flags

Coverage Summary

Prior Authorization, Exceptions & Step Therapy (Provider Actions)

Prior Authorization / Exception / Step Therapy Rules

Response timelines and operational rules for prior authorization (PA), step therapy (ST) exceptions, and related processes.

ALL of the following

Standard decision timeline: For non-urgent (standard) prior authorization or step therapy exception requests, the plan must respond within 72 hours of receiving a completed request.
If the plan fails to respond within this timeframe for a completed request, the request is deemed approved.
Expedited (urgent) decision timeline: For requests based on exigent circumstances where waiting could seriously harm the member, the plan must respond within 24 hours of receiving the request.
If the plan fails to respond within this timeframe for an expedited request, the request is deemed approved.

Policy Summary

PayerCentene

PolicyAON Benefit Experience Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionPrescribers must request prior authorization for drugs listed with 'PA' via CoverMyMeds, phone or fax; Health Net must respond within required timeframes (72h standard, 24h expedited).

SourceLink

On This Page

Missing information: If the plan requests additional information to make a decision, the review timeline is suspended while the plan waits for the requested information. The clock resumes when the plan receives the additional documentation.

Providers should submit complete information to avoid delays.

Approval duration: If an exception or prior authorization is approved, the approval generally continues until the end of the plan year for which it was granted, provided the member remains enrolled and therapy remains appropriate and safe.

If a deemed approval occurs due to missed timelines, coverage is effective for the duration of the prescription, including authorized refills, consistent with the applicable plan rules.

Step Therapy Exception Criteria

Reasons an exception to step therapy may be granted (ANY of the following):

ANY of the following

Provider documents that the required step therapy agent was tried and failed (ineffective) or caused an adverse reaction or intolerance.
Provider documents that the required step therapy agent is contraindicated for the member based on clinical evidence or medical history.
Provider documents that the step therapy agent is clinically inappropriate due to a comorbidity or concomitant therapy that would make the step agent unsafe or ineffective.
Provider documents that the member has previously tried and had an adequate trial of the step agent as part of recent therapy, making repetition clinically unnecessary.
Provider documents that waiting for a step therapy trial would seriously harm the member or that the member’s clinical situation meets exigent/urgent criteria (supports expedited review).

Limited Access (LA) / Specialty (SP) / Mail Order Rules

Operational routing and specialty / limited access rules.

ALL of the following

Limited Access (LA): Certain products are designated LA and are available only at select pharmacies due to manufacturer or regulatory distribution restrictions or because special handling/education is required.
If a drug is LA, the plan will notify the prescriber and member with instructions on where and how to obtain the medication.
Specialty (SP): Specialty drugs are designated SP and must be dispensed through a plan-contracted specialty pharmacy provider. These agents typically require care coordination, special handling, or patient education.
Once approved, a contracted specialty pharmacy will contact the member to arrange delivery and support.
Mail Order: Certain maintenance medications or 90-day supplies may be available via mail-order per plan rules; oral cancer and other categories may have specific supply-day and cost-share rules when dispensed by mail-order specialty pharmacies.
Routing: Prescriptions flagged LA or SP at point of fill will be routed to the appropriate contracted specialty or limited-access dispensing channel; providers should prescribe with the designated dispensing channel in mind.

Formulary entries and constraints (per drug/strength/formulation)

Formulary entries and constraints — by drug/strength/formulation. Use the drug list for full, current per-product limits; examples of administrative controls that may appear on formulary entries include:

ALL of the following

Prior Authorization required: Many specialty, non-preferred, high-cost, or select agents are subject to PA as indicated on the drug list (e.g., specialty biologics, select oral oncolytics, certain contraceptives where noted).
Step Therapy (ST) flags: Some products require a step trial of preferred agents before coverage of the requested product; exceptions permitted per the Step Therapy Exception Criteria.
Quantity Limits (QL): Per-product quantity limits and day-supply caps are enforced at point of fill. Examples include acetylcysteine quantity limits and topical acne product QLs. Requests for quantities above QL require prior authorization with documentation.
Age Limits (AL): Certain products have age restrictions; verification of member age is required and may require authorization if outside specified age ranges (pediatric dosing limits and preventive/OTC designations may apply).
Preventive / OTC flags (PV / RXIOTC): Some drugs are preventive or available OTC; coverage and supply rules follow plan and ACA preventive benefit guidance (prescription required for coverage of OTC preventive drugs in some cases).

Formulary entries and administrative limits

Formulary administrative limits and coverage controls applied by drug/class (examples — consult the Drug List and plan documents for specific products):

ALL of the following

Coverage controls listed by drug/class: May include PA, ST, QL, AL, LA, SP, PV, and RXIOTC flags; each drug entry on the formulary will display applicable requirement abbreviations and any numeric limits or notes.
Duration and refill controls: Approvals may be granted for a specific duration (often through the plan year) and include authorized refills per the approval.
Medical vs Pharmacy benefit designation: Some agents (e.g., depot injections or clinic-administered biologics) may be billed to the medical benefit. Providers should follow plan billing guidance and verify benefit assignment for high-cost or injectable agents.
Specialty pharmacy designation: Specialty drugs require dispensing via contracted specialty pharmacy; failure to use the designated channel may result in non-coverage or claim denial.

Coverage Controls Listed by Drug / Class

Coverage controls and common programmatic requirements by drug/class — representative list (not exhaustive):

ALL of the following

Prior authorization required for many specialty, non-preferred, and select agents; see formulary flags for products requiring PA.
Step therapy enforced for select products; the formulary indicates which agents require prior use of preferred alternatives before coverage of the requested agent.
Quantity limits and day-supply limits are enforced at the pharmacy; overrides require PA and supporting documentation.
Age-based controls apply for pediatric or age-limited products and must be validated at point of fill or via PA.
Some emergency contraceptives and other specialty products have PA or specialty dispensing requirements; check the drug list for specifics.

Prior Authorization

Submit prior authorization

Submit prior authorization: Submit PA or exception requests electronically (e.g., CoverMyMeds) or by phone/fax per plan instructions. Include clinical rationale and relevant records to avoid delays.

Use CoverMyMeds or the plan-specified submission channel
Include diagnosis, prior therapies, and relevant clinical notes

Documentation Required

Provide supporting documentation for step therapy exceptions

Provide supporting documentation for step therapy exceptions: When requesting a step therapy exception, supply documentation that demonstrates trial and failure, contraindication, intolerance, prior adequate trial, or that waiting would cause serious harm.

Document dates and outcomes of prior agent trials
Provide lab results, adverse event documentation, or specialist notes as applicable

Denial Risk

Deemed approval if plan misses timeline

Deemed approval if plan misses timeline: If the plan fails to respond within 72 hours for standard or 24 hours for expedited requests, a completed request is deemed approved for the duration authorized by the policy (including applicable refills).

Ensure submission is complete to trigger the standard timelines
If deemed approved, follow up to obtain written confirmation and coverage details

Billing Rule

Use in-network / specialty pharmacy requirement

Use in-network / specialty pharmacy requirement: Dispense specialty or limited-access drugs through the plan-contracted specialty pharmacy. The contracted specialty pharmacy will coordinate delivery and support once the drug is approved.

Failure to use the contracted specialty pharmacy for SP-designated drugs may result in non-coverage
Limited Access drugs will include instructions on authorized dispensing sites

Billing Rule

Adhere to Quantity Limits

Adhere to Quantity Limits: Observe per-product QLs and day-supply caps at the point of fill; request PA for overrides with supporting documentation.

Examples: acetylcysteine QLs, topical acne product limits
Provide justification and prior-use documentation for quantity override requests

Documentation Required

Age Limits and AL Flags

Age Limits and AL Flags: Verify member age for age-limited products; obtain PA when member age falls outside indicated ranges and clinical justification exists.

Pediatric dosing and age-specific restrictions must be documented
AL flags on the drug list indicate products requiring age verification

Step Therapy

Step therapy must be attempted unless exception applies

Step therapy must be attempted unless exception applies: Unless a documented exception is granted, required step therapy must be completed prior to coverage of the stepped-to agent.

Follow the formulary ST flags for products subject to step therapy
Request exceptions per the Step Therapy Exception Criteria when clinically indicated

Billing Rule

Medical benefit for depot injection

Medical benefit for depot injection: Depot injections and certain clinic-administered therapies may be payable under the medical benefit; bill accordingly and confirm benefit assignment before administration.

Confirm medical vs pharmacy billing for long-acting/depot injectables
Check additional coverage documents for specialty biologics and medical benefit rules

OpenPayer

AON Benefit Experience Drug List

Coverage Summary

Prior Authorization, Exceptions & Step Therapy (Provider Actions)

Coverage Criteria & Controls

Applicable Codes & Formulary Flags

Quick Provider Checklist

Background & Formulary Process

Revision History