Prescription Transition Form

Prescription
Transition Form
How to continue coverage for medications that require prior authorization
We want your first experiences with Health Net of California, Inc. and Health Net Life Insurance Company (Health Net) to be positive,
so we’ve created a program to help ensure that if you’re taking a maintenance medication that requires prior authorization, we can
transition it into our plans as smoothly as possible. This form is to be used only for new members who have transitioned to Health Net
from a different health plan. This program is for prescriptions that you take regularly. Here’s how the program works:
• Health Net will use this transition form to enter authorizations for the medications on this form only in the pharmacy claims
processing system. This will allow your maintenance medication to process without requiring additional authorization.
• This form is to be used for only the prescription drugs below within the first 90 days of eligibility.
• The list below is not a comprehensive list of drugs that require prior authorization from Health Net. For a comprehensive
list of medications that require prior authorization, or if you have questions related to prescriptions not on the list, visit
www.healthnet.com, or if you are a member, contact us at the number on the back of your ID card.
Instructions:
1. A form is not required if a member is currently not taking any of the drugs listed.
2. If the individual listed is currently established on any of the drugs listed below, please circle the correct drug.
3. Fax completed form(s) to the Health Net of California Pharmacy Department at 1-800-314-6223, or mail the form to Health Net
at: PO Box 9103, Van Nuys, CA 91409-9103, ATTN: PHARMACY.
Last name:
First name:
Middle name:
Date of birth:
Member ID number:
Phone number:
Employer group name (if applicable):
Effective date with Health Net:
Brand name (generic name)
Brand name (generic name)
Brand name (generic name)
Aciphex (rabeprazole)
Actonel (risedronate)
Adcirca
Ampyra
Aplenzin
Atelvia
Aubagio
Avodart
Axiron
Azor
Brintellix
Caduet (amlodipine-atorvastatin)
Celebrex (celecoxib)
Clarinex (desloratadine)
Crestor 5 mg
Dexilant Caps
Epipen (epinephrine 0.3 mg)
Epipen Jr. (epinephrine 0.15 mg)
Forfivo XL
Fosamax-D
Gilenya
Glucagon
Gralise
Intermezzo
Jalyn
Lamictal ODT (lamotrigine ODT)
Lamictal XR (lamotrigine XR)
Latuda
Lescol Xl (fluvastatin XL)
Livalo Tablets
Lyrica
Namenda XR
Nexium (esomeprazole)
Nuvigil
Otezla
Oxtellar XR
Pristiq
Promacta
Proscar (finasteride)
Provigil (modafinil)
Rebetol Caps (ribavirin)
Seroquel XR
Revlimid
Rozerem
Savella
Silenor
Stivarga
Taclonex (calcipotriene-betamethasone)
Tarceva
Tecfidera
Tekturna
Tekturna HCT
Testim (testosterone TD Gel)
Treximet
Tribenzor
Trokendi XR
Uceris
Vascepa
Viibryd
Vimovo
Vytorin 10/10
Zohydro ER
Zorvolex
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.
FRM004539EP00 (10/15)