CurrentmhnPolicy N/A

MEDICARE_DRUG_COVERAGE_DETERMINATION_APPLICATION

This is an application form and instructions for Medicare beneficiaries (or their prescribers/authorized representatives) to request a drug coverage determination, prior authorization, or formulary/quantity/step therapy exception from the Health Net Medicare plan. It includes applicant, prescriber, clinical justification, safety, opioid-specific, and submission/contact information and language/access notices.

Policy Summary

Payermhn

PolicyMEDICARE_DRUG_COVERAGE_DETERMINATION_APPLICATION

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionProvider, beneficiary, or authorized representative must complete and submit this form with supporting documentation to request prior authorization, formulary exception, quantity limit exception, tiering exception, or reimbursement.

POLICY UPDATE CHANGES

No material clinical/coverage changes in this update.

10Application Types Listed

24Expedited Decision Hours

1-800-275-4737Primary Contact Phone

Policy summary

This is the Health Net Medicare multilingual Drug Coverage Determination Request form used by beneficiaries, prescribers, or authorized representatives to request coverage determinations including prior authorization, formulary (non‑formulary) exceptions, quantity/ pill limit exceptions, tiering/cost‑share exceptions, or reimbursement for medications. The form includes instructions for expedited (urgent) requests, required clinical and prescriber supporting information (diagnoses with ICD‑10 codes, medication history, current regimen, safety information), opioid‑specific questions, and signature requirements for prescribers when applicable.

Contact and access information and high‑level submission channels are provided: telephone assistance at 1‑800‑275‑4737 (TTY 711) and online via www.healthnet.com or member services; submission by mail to Medicare Pharmacy Prior Authorization Department, P.O. Box 31397, Tampa, FL 33631‑3397 or by fax to 1‑866‑226‑1093. The form may be completed and submitted by the beneficiary, their prescriber, or an authorized representative (with documentation such as CMS‑1696).

Key Summary

Application Types Listed10

Expedited Decision Hours24

Primary Contact Phone1-800-275-4737

StatusCURRENT

SubjectMedicare Drug Coverage Determination Application Form

Scope SummaryApplication form and instructions to request drug coverage determinations, prior authorizations, and formulary/quantity/tiering exceptions for Health Net Medicare beneficiaries, including prescriber clinical justification and submission/contact information.

Application types and when to use this form

Application Types and Required Supporting Statements

The application may be submitted for one or more of the following; prescriber must provide supporting statements for exception/authorization requests where indicated.

Cost-sharing dispute: medication copayment charged is higher than should be

Request reimbursement for medication already paid for by beneficiary

Request prior authorization for a prescription drug (may require supporting information)

Exception to requirement to try other drugs prior to obtaining prescribed drug (non-formulary)

Exception to a plan pill/quantity limit so beneficiary can get the prescribed quantity (non-formulary)

Exception to plan prior authorization rules that must be met prior to obtaining the drug (non-formulary)

Tiering/Cost-share exception: request lower copay tier due to copay differences

Tiering exception because drug moved to a higher cost tier or was removed from formulary

Request for a drug not on the plan's formulary (non-formulary)

Request because drug was or will be removed from formulary during plan year (non-formulary)

This document is informational and initiates Health Net coverage determination workflows — completing and submitting this form starts the prior authorization, exception, or reimbursement review process but does not guarantee that coverage will be approved. Decisions follow the plan’s review procedures, including standard and expedited timeframes and required prescriber supporting information.

Expedited (urgent) decision requests

Expedited (Urgent) Decision Request

Criteria and process for requesting expedited review:

Prescriber certifies that waiting 72 hours for a standard decision could seriously harm the beneficiary's life, health, or ability to regain maximum function

If prescriber supports urgency, Health Net will provide decision within 24 hours24 hours if prescriber supports

If prescriber does not provide support, Health Net will determine whether expedited decision is warranted

Note: If requesting reimbursement for medication already obtained, expedited decision is not available

Denial Risk

Expedited decision limitation for reimbursement requests

Reimbursement requests (requests to be paid back for drugs already obtained) are not eligible for expedited 24-hour decisions and may be delayed if the prescriber does not certify urgency or expedited criteria are not met.

Threshold

Expedited decision timeframeDecision within 24 hours if prescriber certifies waiting 72 hours could seriously harm beneficiary; if prescriber does not provide support, Health Net will determine whether expedited decision is warranted.

Required prescriber supporting information

Required Prescriber Supporting Information

Prescriber must complete clinical justification section when applicable:

Prescriber identifying information and signature

Diagnosis(es) and corresponding ICD-10 code(s) for which the drug is being requested

Medication details: name, strength, route, frequency, expected duration, start date, quantity per 30 days

Medication history for condition: prior drugs tried, doses, dates, and outcomes (including failures/intolerances)

Current medication regimen for the condition

Allergies

If drug has FDA-listed contraindications or interactions, prescriber must explain and discuss benefit-risk and monitoring plan

If beneficiary >65 years, prescriber must state whether benefits outweigh risks

Documentation Required

Prescriber supporting statement required

Prescriber must provide supporting statement on pages 3–4 as applicable including diagnosis(es) with corresponding ICD-10 code(s), medication history (drugs tried, doses, dates, outcomes), current therapy, medication safety information (contraindications/interactions/monitoring), and prescriber signature.

Opioid-specific requirements

Opioid-specific Questions (if applicable)

If the requested medication is an opioid, prescriber must provide:

Total daily morphine equivalent dose (MED) in mg/daymg/day

Whether beneficiary has other opioid prescribers and details

Whether the listed MED is medically necessary

Whether lower MED is insufficient to control pain

Whether alternatives were tried and resulted in adverse events or failures and details (max dose and duration tried)

Documentation Required

Opioid-specific documentation — include MED and supporting details

If the requested medication is an opioid, include the total daily morphine equivalent dose (MED) in mg/day and provide supporting documentation about other opioid prescribers, medical necessity of the listed MED, whether lower MEDs are insufficient, and prior alternative trials with outcomes (max dose and duration) when applicable.

Application reasons and justifications (checkbox options)

Application Reasons / Justifications (checkbox options)

Prescriber should select applicable reasons and provide specific explanations:

Alternative drugs are contraindicated, likely ineffective, or likely to cause adverse outcomes — must specify why

Beneficiary would be harmed by having to meet prior authorization requirements — explain expected adverse clinical outcomes

Beneficiary is stable on current drug and changing therapy risks significant adverse clinical outcomes — must describe

Need for different formulation or higher dose — must describe prior attempts, medical reason, and why alternative dosing regimens are not suitable

Formulary tier exception request — must document prior formulary/preferred drug trials, outcomes, contraindications, or other rationale

Other — free-text explanation

Prior Authorization

Submit Medicare Drug Coverage Determination Application

Provider, beneficiary, or an authorized representative must complete and submit this Medicare Drug Coverage Determination Application form with supporting documentation to request prior authorization, formulary/quantity/tier exceptions, or reimbursement.

Prior Authorization

Authorized representative documentation

If an authorized representative submits the application, include documentation showing authority to act (completed CMS‑1696 form or equivalent) with the submission.

Submission channels and contact information

Billing Rule

Submission channels and contact

Submit the form and supporting information by mail, fax, or phone: Mail to Medicare Pharmacy Prior Authorization Department P.O. Box 31397 Tampa, FL 33631-3397; Fax to 1-866-226-1093; Phone 1-800-275-4737 (TTY 711).

Mail: Medicare Pharmacy Prior Authorization Department P.O. Box 31397 Tampa, FL 33631-3397
Fax: 1-866-226-1093
Phone: 1-800-275-4737 (TTY 711)

Quick Contacts

Primary Contact Phone1-800-275-4737

Fax1-866-226-1093

MailMedicare Pharmacy Prior Authorization Department P.O. Box 31397 Tampa, FL 33631-3397

TTY711

Language, access, and civil rights information

The form includes multilingual access and civil‑rights information. Health Net provides free language assistance services and aids for people with disabilities (for example, qualified interpreters, translated materials, braille and large‑print documents); members are instructed to call 1‑800‑275‑4737 (TTY: 711) for help in their language or for disability‑related accommodations.

The form also includes nondiscrimination and civil rights notice language stating that Health Net complies with applicable federal civil rights laws and will not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy and sexual orientation), and provides contact information for filing complaints (including a 1557 coordinator contact and the U.S. Department of Health and Human Services Office for Civil Rights).