Frequently Asked Questions

All female Health Net members can self-refer, within their Participating Physician Group, for Obstetrical and Gynecological (OB/GYN) services. For other referrals, your Primary Care Physician will determine if an office visit is necessary. Generally, Primary Care Physicians refer exclusively to specialist physicians who are Participating Providers within their common Participating Physician Group.

When the Primary Care Physician refers a member for ongoing specialist treatments, the member does not need a referral before each visit. However, the Primary Care Physician must initiate all specialty referrals. If the specialist recommends that the member see another doctor, the Primary Care Physician must issue another referral.

After you become eligible with Health Net, you must call your Primary Care Physician before making any future appointments with the specialist. All specialty care requires a referral from the Primary Care Physician/physician group, and they arrange for the coordination of any future services.

To request an authorization for a second opinion, contact Health Net Member Services at 1-800-522-0088. Health Net will review the request in accordance with Health Net’s second opinion policy. For more detailed information see Section 3 of your FEHB brochure.

Health Net members do not need a referral to receive chiropractic care from a chiropractor participating in the American Specialty Health Plan (ASH) network. For the most current listing of participating chiropractors go to Americanspecialtyhp.com or call the ASH Member Services Department at 1-800-678-9133.

Health Net members seeking treatment for mental health or substance abuse do not have to contact their Primary Care Physician or Medical Group. Instead, FEHB members call Managed Health Network (MHN) at 1-888-779-2236, and MHN will direct them to the appropriate contracting provider of care.

All female Health Net FEHB members in California can self-refer, within their Participating Medical Group, for Obstetrical and Gynecological (OB/GYN) services.

For all other specialty care, members need a referral from their Primary Care Physician or Medical Group, unless the contracted Medical Group allows members to receive some specialty care without a referral or authorization.

The Health Net website and Provider Directories indicate which Medical Groups offer direct referrals to specialists within the same medical group. For the most up-to-date information on direct referrals contact your medical group or primary care physician.

Yes. Through our Decision Power program, all members have access to Health Coaches who are specially trained health professionals and can provide unbiased, evidence-based health information and coaching support. They help members carefully consider the potential risks, benefits and outcomes of treatment options so they can better evaluate available health care choices.
Health Coaches are available 24 hours a day, 7 days a week. Health Coaches can be reached via telephone or online by logging in to www.healthnet.com > Decision Power Health & Wellness.

Members must always contact their Participating Physician Group and/or member’s Primary Care Physician as soon as possible whenever emergency services have been received. After the member’s medical problem ceases to be an emergency, follow-up care must be performed or authorized by the member’s physician group or it will not be covered (see Section 5 (d) of your FEHB brochure).

Health Net defines an emergency as a sudden injury or illness which could threaten life, limb, or internal organs. Urgently needed care is defined as immediate treatment for a sudden injury or illness that is required to prevent serious health deterioration. For a more detailed description of emergency services please see Section 5 (d) of your FEHB brochure.

No, you do not need a referral to see a specialist. You can seek services from any licensed specialist. However, utilizing a PPO contracted specialist will allow you to take advantage of our reduced rates negotiated with the provider.

Although it is not a requirement to pre-authorize treatment, it is strongly recommended (for treatments over $300.00) so you will know in advance: 1) if the service is a covered benefit; 2) The benefit amount to be paid by the Plan; 3) how much you may have to pay for the treatment.

Coinsurance is the percentage of the fee charged by the dentist that is the member’s responsibility. For example: If a procedure is covered at 80% by the insurance company, the remaining 20% is the member’s responsibility.

An annual maximum is the maximum insurance benefit paid out by the plan for each covered member per calendar year. If a member has met the annual maximum no further benefits will be paid until the next calendar year.

This is the dollar amount of the covered charges (within a plan year) that the member must pay prior to the plan beginning to pay out benefits. Each member of the family has their own deductible (maximum of three deductibles per family) to meet in a benefit year.

Using a PPO contracted dental provider allows you to take advantage of our negotiated contract rate with our providers thus lowering a member's out-of-pocket costs.

The primary distinction is that a PPO plan allows the member to choose either a contracted PPO network provider or any licensed dentist for covered services. You do not need to assign yourself or your covered family members to one particular dentist.

Members on maintenance medication can receive a 90-day supply delivered directly to their home or office by completing our mail order prescription drug form. Members must obtain an original prescription from your participating physician for a 90-day supply (plus refills up to the equivalent of one year) and include two
copayments per 90-day supply. The prescription will arrive within 14 days from the day you mail your order. You can obtain a mail order form by calling Member Services at 1-800-522-0088, or by using the Ordering Materials section on this website or downloading a claim form by logging into the Member Services section of the website.

If an urgent medical condition or emergency situation arises and you need to have a prescription filled, you may need to pay for it out of pocket and seek reimbursement from Health Net by submitting a prescription claim form. Claim forms can be obtained by calling Member Services at 1-800-522-0088, using the Ordering Materials section on this web site or downloading a claim form by logging into the Member Services section of this website.

A brand name drug is a drug that has been given a brand name by its manufacturer. When a new drug is developed, the manufacturer applies for a patent, which also gives the manufacturer the right to name its product. Manufacturers of drugs pick unique, usually memorable names to promote product recognition.

Generic drugs are the pharmaceutical equivalent of brand name drugs whose patents have expired and are produced by multiple drug companies, usually at a lower cost. Generics are FDA-tested, and approved to meet the same standards of safety and effectiveness as their brand name versions.

When a medication requires prior authorization, safety steps are followed to ensure certain clinical criteria are met before medication is dispensed. First, your doctor must contact Health Net to provide information on the medical reasons for the medication. Upon receiving the necessary information, Health Net will assess this information based on established clinical criteria for the particular product. If the clinical criteria are met, an authorization will be issued for the medication.

If an member chooses to receive a drug for a covered benefit that is not on the Health Net Recommended Drug List, it will be dispensed for the non-formulary copayment. However, some drugs, for the safety of the member, require prior authorization.

The Health Net Recommended Drug List is developed and maintained by the Health Net Pharmacy and
Therapeutics (P&T) Committee. Before deciding whether to include a drug on the List, the committee reviews
medical literature and consults with specialists to assess drugs for the following:

• Safety
• Effectiveness
• Cost-effectiveness (when there is a choice between drugs having the same effect, the less costly drug will be added to the List)
• Side effect profile
• Therapeutic outcome

The P&T committee meets annually to review medications and to establish Recommended Drug List policies and
procedures. The P&T Committee consists of practicing physicians and pharmacists who review medications based
on clinical efficacy, safety and overall value. In order to keep the List current, the committee reviews its contents at
least annually and the list is updated as new information and medications become approved.