Health Net Prior Authorization Lookup
Latest Health Net prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-05-012026 Step Therapy CriteriaDefines Health Net's 2026 step therapy requirements for covered antidepressants, antipsychotics (oral), dextromethorphan/bupropion, and trazodone products; applies to prior authorization and coverage determinations for members under this payer.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Pharmacy and specialty drug formulary — coverage criteria (partial list)Governs coverage, prior authorization (PA), quantity limits (QL), and medical necessity designations for pharmacy and specialty drugs; applies to prescribers and pharmacists processing Health Net member benefits.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Avutometinib; Defactinib (Avmapki Fakzynja Co-Pack) coverage criteriaDefines medical necessity criteria, prior authorization, and coverage parameters for the co-packaged combination of avutometinib and defactinib (Avmapki Fakzynja Co-Pack), primarily for KRAS‑mutated recurrent low-grade serous ovarian cancer; affects prescribers and payers reviewing initial and continuation requests.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-25Duobrii (halobetasol propionate/tazarotene) topical lotion — coverage criteriaPolicy governs medical necessity criteria, prior authorization, and coverage limits for Duobrii topical lotion for plaque psoriasis in adults across Health Net lines of business covered by this policy.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-01Desloratadine (Clarinex) and Desloratadine/Pseudoephedrine (Clarinex-D) prior authorizationThis policy governs prior authorization and coverage criteria for desloratadine (Clarinex) and desloratadine/pseudoephedrine (Clarinex-D 12 Hour) for commercial lines of business under Health Net/Centene Corporation.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-05-01Formulary alternatives and restrictions for non-covered drugsThis document lists common drugs that are not covered on the Health Net formulary and suggests covered alternative drugs, plus formulary restrictions such as prior authorization (PA) and quantity limits (QL); it is intended for providers and pharmacists applying the Health Net formulary.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-03-01Dupilumab (Dupixent) coverage and medical necessity criteriaClinical policy governing medical necessity, prior authorization, dosing limits, and continuation criteria for dupilumab (Dupixent) for multiple FDA‑approved and selected off‑label indications for Health Net commercial lines of business in NC.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2025-03-01Eculizumab (Soliris) and biosimilars (Bkemv, Epysqli) — coverage criteriaPolicy governing medical necessity criteria, prior authorization, and continued use for eculizumab (Soliris) and biosimilars (Bkemv, Epijkstra) across covered lines of business; affects providers prescribing these agents for PNH, aHUS, gMG, NMOSD, and other indications for Health Net/Centene products.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-20Concizumab-mtci (Alhemo) prophylaxis for hemophilia A and BDefines medical necessity and prior authorization criteria for Alhemo (concizumab-mtci) when used for routine prophylaxis to prevent or reduce bleeding in patients ≥12 years with hemophilia A or B, with or without inhibitors. Applies to Health Net lines of business listed in the policy.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-01Clinical Policy: Seladelpar (Livdelzi)Policy governs medical necessity and prior authorization criteria for Seladelpar (Livdelzi) for treatment of primary biliary cholangitis (PBC) for Health Net (Centene-affiliated) lines of business including Commercial, HIM, and Medicaid.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-10-01Leuprolide acetate and leuprolide mesylate coverageDefines medical necessity and prior authorization criteria for leuprolide acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped) and leuprolide mesylate (Camcevi) for Health Net (Medicaid) members.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-09-01Tislelizumab-jsgr (Tevimbra) coverageDefines medical necessity and prior authorization criteria for tislelizumab-jsgr (Tevimbra) for adults with specified malignancies and describes coding implications and approval durations for Health Net lines of business.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-30Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo) coverageDefines medical necessity and prior authorization criteria for injectable and oral solution methotrexate products (Otrexup, Rasuvo, Xatmep, Reditrex, Jylamvo) across Health Net lines of business; applies to providers requesting coverage for these products.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-19Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)Policy governing medical necessity and prior authorization criteria for Enstilar topical foam for treatment of plaque psoriasis in covered members; applies to Health Net lines of business including Commercial, HIM, and Medicaid where noted.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-19Neomycin/fluocinolone (Neo-Synalar) topical cream coverage criteriaPolicy governs medical necessity and prior authorization criteria for Neo-Synalar topical cream for members across Commercial, HIM, and Medicaid lines of business.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-17Clinical Policy: Abaloparatide (Tymlos)Policy governing medical necessity, prior authorization, and coverage criteria for abaloparatide (Tymlos) for treatment of postmenopausal and male osteoporosis for Health Net lines of business (Commercial, HIM, Medicaid). Applies to providers requesting coverage under the plan.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-02Clinical Policy: Donanemab-azbt (Kisunla)Defines medical necessity and prior authorization criteria for donanemab-azbt (Kisunla) in members with mild cognitive impairment due to Alzheimer disease or mild Alzheimer dementia for Health Net lines of business.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-06-01Clinical Policy: Aprocitentan (Tryvio)Defines medical necessity and prior authorization criteria for aprocitentan (Tryvio) for treatment of hypertension in adults within Health Net/Centene-affiliated plans.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-06-01Clinical Policy: Vadadustat (Vafseo)Defines medical necessity, prior authorization and continuation criteria for vadadustat (Vafseo) in adults with anemia due to chronic kidney disease who have been receiving dialysis for at least three months; applies to Health Net lines of business including Commercial, HIM, and Medicaid.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-05-23Pegunigalsidase Alfa (Elfabrio) — Coverage CriteriaDefines medical necessity and prior authorization criteria for Elfabrio (pegunigalsidase alfa-iwxj) for treatment of adults with confirmed Fabry disease for Health Net lines of business including Commercial, HIM, and Medicaid.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-05-01Clinical Policy: Glycerol Phenylbutyrate (Ravicti)Policy governs medical necessity criteria, prior authorization, and continuation requirements for glycerol phenylbutyrate (Ravicti) for treatment of urea cycle disorders across Health Net lines of business (Commercial, HIM, Medicaid). It specifies diagnostic confirmation, prescriber experience, stepwise redirection to alternatives, dosing limits, and approval durations.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-05-01Ferric Carboxymaltose (Injectafer) coverageDefines medical necessity criteria, prior authorization and continuation rules for ferric carboxymaltose (Injectafer) for commercial, HIM and Medicaid lines of business in Health Net of California.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-16Selexipag (Uptravi) — Coverage CriteriaDefines medical necessity and prior authorization criteria for selexipag (Uptravi) for treatment of pulmonary arterial hypertension (PAH) across Health Net lines of business including Commercial, HIM, and Medicaid.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-01Clinical Policy: Asfotase Alfa (Strensiq)Policy governs medical necessity and prior authorization criteria for asfotase alfa (Strensiq) for perinatal/infantile- and juvenile-onset hypophosphatasia across commercial, HIM and Medicaid lines of business.All Health Net updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-01Clinical Policy: Ranibizumab (Byooviz, Cimerli, Lucentis, Susvimo)This policy governs medical necessity criteria, dosing limits, prior authorization and coverage decisions for ranibizumab products (Lucentis, Byooviz, Cimerli, Susvimo) across Commercial, HIM and Medicaid lines of business for Health Net/Centene-affiliated plans.All Health Net updates
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Tool Description
Search Health Netprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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