Reminder: Revised Prior Authorization Requirements for CA Commercial Members

As a reminder of the communication that was sent out several weeks ago, we want you to be aware of PAL changes that may affect your clients’ health care coverage. Please review the following information. Changes and effective date vary based on type of plan.

 

Plans offered by Health Net of California, Inc.

We have revised our PAL requirements for commercial plans, including Direct Network HMO, HSP, and POS effective January 1, 2017. Significant changes are listed below.

 

New medical benefit pharmaceutical requires prior authorization

  • Cinqair, Eylea, Macugen, Nucala, Probuphine, and Visudyne

 

 

New outpatient items requiring prior authorization

 

All commercial plans

  • Total ankle replacement

 

Direct Network HMO plans, HSP group plans and POS plans

  • Balloon sinuplasty
  • Capsule endoscopy
  • Penile implant

 

POS plans

  • Behavioral health and substance abuse services

 

Prior authorization no longer required

  • Makena™

 

 

Plans underwritten by Health Net Life Insurance Company

We have revised our PAL requirements for commercial plans, including EPO, PPO, out-of-state PPO1, and Flex Net, which go into effect upon the member’s 2017 renewal date. Significant changes are listed below.

 

 

New medical benefit pharmaceutical requires prior authorization

  • Cinqair, Eylea, Macugen, Nucala, Probuphine, and Visudyne

 

 

New outpatient items requiring prior authorization

 

All commercial plans

  • Total ankle replacement

 

EPO group plans

  • Balloon sinuplasty
  • Capsule endoscopy
  • Penile implant

 

PPO plans

Behavioral health, limited to:

  • outpatient psychological testing
  • electroconvulsive therapy
  • neuropsych testing
  • transcranial magnetic stimulation

 

Prior authorization no longer required

  • Makena™

 

Accessing prior authorization requirements

A complete copy of the new January 1, 2017, PAL requirements is linked here for your reference.

For a copy of the current PAL requirements, members can:

  • Log in to our website at healthnet.com. Then, under My Coverage, click Preauthorizations > Prior Authorization List.
  • Call Health Net at 1-800-522-0088 (TTY: 711).

 

Need more information?

Members can contact the Health Net Customer Contact Center online at www.healthnet.com,or by telephone at 1-800-522-0088 (TTY: 711). Our Customer Contact Center is available Monday through Friday, 8:00 a.m. to 6:00 p.m., except federal holidays.

 

 

 

 

 

 

 

 

 

Health Net HMO, HSP, EOA, and POS plans are offered by Health Net of California, Inc. Health Net PPO, EPO, and Flex Net insurance plans are underwritten by Health Net Life Insurance Company. Health Net of California, Inc. and Health net Life insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.

 

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Susan Peters