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UÊLimited Distribution: Some drugs may besubject to limited distribution or restricted access.This means that a drug may only be available atone or a limited number of pharmacies. Limiteddistribution may be due to the following reasons:1. The FDA has restricted distribution of a drugto certain facilities, pharmacies or physicians,or2. Certain drugs require special handling,coordination of care, or patient education thatcannot be received at a retail pharmacy.You should talk to your doctor or pharmacist fordetails about acquiring limited distribution drugs.UÊPrior Authorization: Some drugs requireprior authorization due to coverage, clinicaleffectiveness, or safety considerations. This meansthat you or your physician must request approvalfrom Health Net before the drug will be covered.UÊProduct Selection Penalty: You may be chargeda product selection penalty if you receive a brandname drug when a generic equivalent is available.This means you may be charged your brand tiercopayment plus the difference in cost between thebrand and generic drugs.UÊQuantity Limits: For some drugs, Health Netlimits the amount of the drug that we will coverUÊStep Therapy: In some cases, Health Net requiresyou to first try certain drugs to treat your medicalcondition before we will cover another drug forthat condition. For example, if Drug A and DrugB both treat your medical condition, Health Netmay not cover Drug B unless you try Drug A first.If Drug A is found in your recent Health Netprescription claims history, we will automaticallyapprove Drug B.UÊ30-day Supply: Certain drugs will not be coveredfor more than a 30-day supply. This limitationapplies at retail, mail order, specialty and homeinfusion pharmacies.IntroductionUÊGender Limit: Some drugs are only covered formales or females based on manufacturer, FDA, orclinical recommendations.based on manufacturer, FDA, or clinical dosingor treatment recommendations. This may replaceyour standard days supply limit.\UÊMedicare Part B vs. Part D: For some drugs,their intended use, the way they are administered,and other factors must be reviewed to determineif they qualify for coverage under Medicare PartB or Medicare Part D. A pharmacy may not beable to fill your prescription until it is determinedunder which Medicare benefit the drug qualifiesfor coverage. Your doctor may need to supplyadditional information to support that the drugqualifies for coverage under your Medicare Part Dbenefit. If the drug qualifies for coverage underMedicare Part B and you do not have MedicarePart B coverage through Health Net, the claimwill be denied for coverage under Health Net.You can find out if your drug has any restrictionsor limits by looking in the Limits column onthe formulary. For a complete description ofabbreviations found in the Limits column, turn topages 11 – 12 of this booklet.You can ask Health Net to make an exceptionto these restrictions or limits. See the section,“How do I request an exception to the Health NetMedicare Part D Formulary?” for informationabout how to request an exception.how do i request an exceptionto the health net medicarepart d formulary?You can ask us to make an exception to our coveragerules. There are several types of exceptions that youcan ask us to make.UÊ9 ÕÊV Ê Ã ÊÕÃÊÌ ÊV ÛiÀÊÞ ÕÀÊ ÀÕ}ÊiÛi Ê vÊ ÌÊ ÃÊ ÌÊon the formulary.UÊ9 ÕÊV Ê Ã ÊÕÃÊÌ ÊÜ ÛiÊV ÛiÀ }iÊÀiÃÌÀ VÌ ÃÊ ÀÊlimits on your drug. For example, for certaindrugs, Health Net may limit the amount ofthe drug that we will cover. If your drug has aquantity limit, you can ask us to waive the limitand cover more.UÊ9 ÕÊV Ê Ã ÊÕÃÊÌ Ê«À Û iÊ Ê } iÀÊ iÛi Ê vÊcoverage for your drug. If your drug is containedin the non-preferred tier or the Injectable tier,6

you can ask us to cover it for a preferred tiercopayment. Please note, if we grant your requestto cover a drug that is not on the formulary,you may not ask us to provide a higher level ofcoverage for the drug. Also, you may not ask usto provide a higher level of coverage for drugs inthe Specialty tier.Generally, Health Net will only approve yourrequest for an exception if the alternative drugsincluded on the formulary, the preferred drugs oradditional utilization restrictions would not be aseffective in treating your condition and/or wouldcause you to have adverse medical effects.You should contact us to request an exception.When requesting an exception we require astatement from your physician supporting yourrequest. Generally, we must make our decisionwithin 72 hours of receiving your prescribingphysician’s supporting statement. You can requestan expedited (fast) exception if you or your doctorbelieve that your health could be seriously harmedby waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give youa decision no later than 24 hours after we receiveyour prescribing physician’s supporting statement.7

which health net medicare part d formulary applies to you?This document contains three formularies titled Formulary A, Formulary B and Formulary C. Todetermine which formulary applies to you, locate your Plan Name and State in the table below. If you arenot sure of your plan name, you can find it in your EOC.STATEAZHealth Net Healthy Heart ICAHealth Net Seniority Plus AmberCAHealth Net Seniority Plus RubyCAHealth Net Options Plus VioletCAHealth Net NavyCTHealth Net RubyAZ, CTHealth Net SageOR, WAHealth Net VioletAZ, OR, WAHealth Net PearlCA, GA, HI, MA,NC, NM, NY, TX,VA, WAHealth Net Orange Option 2 (PDP)All StatesHealth Net Orange Option 1 (PDP)All StatesHealth Net Value Orange Option 2 (PDP)All StatesHealth Net Healthy Heart IICAHealth Net SageAZ, CTFormulary A\Health Net AmberFORMULARYIntroductionPLAN NAMEFormulary BFormulary C8

formulary a and formulary b tier descriptionsTo determine how much you will be required to pay for a drug, the abbreviations in the table belowappear in the Brand Tier and Generic Tier columns on the formulary. The copayment or coinsurance levelyou will be required to pay is displayed in the copayment/coinsurance column. If you do not know yourcopayment or coinsurance for each tier, please refer to your Summary of Benefits or EOC.ABBREVIATION COPAYMENT/ COINSURANCEDESCRIPTION1Tier 1 copaymentPreferred generic drugs.2Tier 2 copaymentPreferred brand drugs. A product selectionpenalty* may be applied when a brand namedrug is dispensed and a generic equivalent isavailable.3Tier 3 copaymentNon-preferred generic and brand drugs. Aproduct selection penalty* may be appliedwhen a brand name drug is dispensed and ageneric equivalent is available.JInjectable Tier copaymentLower cost injectable drugs. These drugs arelimited to a maximum 30-day supply per fill.SSpecialty Tier copayment orHigh-cost oral and injectable drugs. Specialtycoinsurancedrugs are limited to a maximum 30-day supplyper fill and are not eligible for exceptions forpayment at a lower tier.*Product Selection PenaltyYou may be charged a product selectionpenalty if you receive a brand name drugwhen a generic equivalent is available. Thismeans you may be charged your brandtier copayment plus the difference in costbetween the brand and generic drugs.NFNonformulary – If Health NetDrugs not covered on Health Net’s Medicareapproves an exception request Part D formulary. You may request anfor a nonformulary drug, theexception from Health Net to cover theseTier 3 copayment will apply. A drugs. See the section, “How do I request anproduct selection penalty may exception to the Health Net Medicare Partbe applied.D formulary?” for information about how torequest an exception.9

formulary c tier descriptionsTo determine how much you will be required to pay for a drug, the abbreviations in the table belowappear in the Brand Tier and Generic Tier columns on the formulary. The copayment or coinsurance levelyou will be required to pay is displayed in the copayment/coinsurance column. If you do not know yourcopayment or coinsurance for each tier, please refer to your Summary of Benefits or EOC.JS*Introduction4COPAYMENT/ COINSURANCEDESCRIPTIONTier 1 copaymentSpecific generic drugs available for 0.Tier 2 copaymentPreferred generic drugs.Tier 3 copaymentPreferred brand drugs. A product selectionpenalty* may be applied when a brand namedrug is dispensed and a generic equivalent isavailable.Tier 4 copaymentNon-preferred generic and brand drugs. Aproduct selection penalty* may be appliedwhen a brand name drug is dispensed and ageneric equivalent is available.Injectable Tier copaymentLower cost injectable drugs. These drugs arelimited to a maximum 30-day supply per fill.Specialty Tier copayment orHigh-cost oral and injectable drugs. Specialtycoinsurancedrugs are limited to a maximum 30-day supplyper fill and are not eligible for exceptions forpayment at a lower tier.Product Selection PenaltyYou may be charged a product selectionpenalty if you receive a brand name drugwhen a generic equivalent is available. Thismeans you may be charged your brandtier copayment plus the difference in costbetween the brand and generic drugs.\ABBREVIATION12310

how do i use the formulary?There are two ways to find your drug within theformulary:Alphabetical ListingThe index at the end of this booklet provides analphabetical list of all of the drugs included in theformulary. Both brand name drugs and genericdrugs are listed in the index. Next to your drug,you will see the page number where you can findcoverage information. Turn to the page listed inthe index and find the name of your drug in thefirst column of the list.Medical ConditionThe drugs in the formulary are grouped intocategories depending on the type of medicalconditions that they are used to treat. For example,drugs used to treat a heart condition are listedunder the category, “Cardiovascular Agents – HeartDrugs.” If you know what your drug is used for,look for the category name within the formulary.Then look under the category name for your drug.how do i read the formulary?If you have trouble finding your drug, turn to theindex at the end of this booklet.Brand and Generic Drug NamesThe name of each drug can be found in the firstcolumn of the formulary. Brand name drugs arein uppercase (example: ZOCOR) and genericdrugs are in lowercase (example: simvastatin).When there is a brand name drug with a genericequivalent available, the drugs will be listed on thesame line with the generic drug in parentheses,for example: ZOCOR (simvastatin). If there is nogeneric equivalent available, only the brand namewill appear.UÊ Ã }Ê}i iÀ VÊ ÀÕ}ÃÊ ÞÊÃ } wV Ì ÞÊ ÜiÀÊyour out-of-pocket costs because generic drugsare generally lower in cost than brand namedrugs.UÊ/ iÊ ÊÌ À Õ} ÞÊÀiÛ iÜÃÊ Ê}i iÀ VÊ ÀÕ}ÃÊto ensure they are safe and effective. A genericdrug has the same active ingredients as the brandname counterpart, but may differ in size, shape,and/or color because it is made by a differentmanufacturer.Tier StatusThe tier status is shown to the right of the drugname under your corresponding formularycolumns.LimitsThe information in the Limits column tells youif there are any limits or restrictions on yourdrug. For a complete description of abbreviationsfound in the Limits column please refer to theAbbreviations table beginning on page 11.BRAND DRUGFORMULARY AFORMULARY BFORMULARY CLIMITS(GENERIC DRUG) BRAND GENERIC BRAND GENERIC BRAND GENERICTIERTIERTIERTIERTIERTIERTherapeutic Category NameTherapeutic Class NameBRAND NAME2*12*13*1QL, PA,(generic name)B/D, 30DSBRAND NAME3NF4LD, STBrand drug only;generic not available*Product Selection PenaltySample of abbreviations; Turnto pages 11-12 for a completedescription of abbreviations*Product Selection Penalty: You may be charged your copayment plus the difference in cost between thebrand and generic drugs.11

abbreviationsThe table below provides a description of abbreviations that appear in the Limits column on the formulary:Introduction\ABBREVIATION COPAYMENT/ COINSURANCEDESCRIPTIONALAge LimitSome drugs may require prior authorization ifyour age does not meet manufacturer, FDA,or clinical recommendations.B/DMedicare Part B vs. Part DSome drugs may be billed to the MedicarePart B or Part D benefit, depending on theintended use and other factors. A pharmacymay not be able to fill your prescription until itis determined under which Medicare benefitthe drug qualifies for coverage. Your doctormay need to supply additional information tosupport that the drug qualifies for coverageunder your Medicare Part D benefit. If thedrug qualifies for coverage under MedicarePart B and you do not have Medicare Part Bcoverage through Health Net, the claim willbe denied for coverage under Health Net.GLGender LimitSome drugs are only covered for males orfemales based on manufacturer, FDA, orclinical recommendations.LDLimited DistributionSome drugs may be subject to limiteddistribution or restricted access. This means thata drug may only be available at one or a limitednumber of pharmacies. Limited distribution maybe due to the following reasons:UÊ/ iÊ Ê ÃÊÀiÃÌÀ VÌi Ê ÃÌÀ LÕÌ Ê vÊ Êdrug to certain facilities, pharmacies orphysicians, orUÊ iÀÌ Ê ÀÕ}ÃÊÀiµÕ ÀiÊëiV Ê }]Êcoordination of care, or patient educationthat cannot be received at a retail pharmacy.PAPrior AuthorizationYou should talk to your doctor or pharmacistfor details about acquiring limited distributiondrugs.Some drugs require prior authorization dueto coverage, clinical effectiveness, or safetyconsiderations. This means that you or yourphysician must request approval fromHealth Net before the drug will be covered.12

ABBREVIATION COPAYMENT/ COINSURANCEDESCRIPTIONQLQuantity LimitFor some drugs, Health Net limits theamount of the drug that we will cover basedon manufacturer, FDA, clinical dosing ortreatment recommendations.ST30DSStep Therapy30-day supplyhealth net’s transitionprogramThe Health Net transition program is designed toensure a safe transition for members to theHealth Net prescription drug benefit. This programalso applies to existing members with changes in theirlevel of care. A level of care change occurs when youare discharged from a hospital or moved to or froman Assisted Living or Long Term Care facility.As a new member in our plan you may be takingdrugs that are not on the formulary. Or, you maybe taking a drug that is on the formulary withrestrictions or limits. For example, you may need aprior authorization from us before your prescriptioncan be filled. You should talk to your doctor todecide if you should switch to a drug that we coveror request an exception so that we will cover the drugyou take. While you talk to your doctor to determinethe right course of action for you, we may cover yourdrug in certain cases during the first 90 days you are amember of our plan.13This may replace your standard days supplylimit.In some cases, Health Net requires you tofirst try certain drugs to treat your medicalcondition before we will cover another drugfor that condition.For example, if Drug A and Drug B bothtreat your medical condition, Health Netmay not cover Drug B unless you try DrugA first. If Drug A is found in your recentHealth Net prescription claims history, we willautomatically approve Drug B.Certain drugs will not be covered for morethan a 30-day supply. This limitation applies atretail, mail order, specialty and home infusionpharmacies.During this time, for each of your drugs that is noton the formulary or your ability to get your drugs islimited, we will cover a one-time temporary 30-daytransition supply (unless you have a prescriptionwritten for fewer days) when you go to a networkpharmacy.If you are a resident of a long-term care facility, wewill cover a temporary 34-day transition supply(unless you have a prescription written for fewerdays). We will cover more than one refill of thesedrugs for the first 90 days you are a member of ourplan. If you need a drug that is not on the formularyor your ability to get your drugs is limited, but youare past the first 90 days of membership in our plan,we will cover a 34-day emergency supply of thatdrug (unless you have a prescription written for fewerdays) while you pursue an exception.

FOR MORE INFORMATIONFor more detailed information about your Health Net prescription drug coverage,please review your EOC and other plan materials.If you have questions about Health Net, please call our Customer Service departmentat the toll-free number listed at the front of this booklet, or visit www.healthnet.com.\IntroductionIf you have general questions about Medicare prescription drug coverage, please callMedicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week.TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.14

BRAND DRUG (generic AmphetaminesADDERALL (amphetamine-dextroamphetamine) ORALADDERALL XR 10MG CP24 ORALADDERALL XR 5MG, 15MG, 20MG, 25MG, 30MGCP24 ORALDESOXYN (methamphetamine hcl) ORALDEXEDRINE (dextroamphetamine sulfate) ORALDEXTROSTAT (dextroamphetamine sulfate) ORALLIQUADD GCAPS ORALVYVANSE 30MGCAPS ORALAnalepticsCAFCIT (caffeine citrated) INJECTIONCAFCIT (caffeine citrated) ORALCAFFEINE/SODIUM BENZOATE INJECTIONDOPRAM (doxapram hcl) INTRAVENOUSAnti-Obesity AgentsXENICAL ORALAttention-Deficit/Hyperactivity Disorder MGCAPS,25MGCAPS ORALSTRATTERA 80MGCAPS,100MGCAPS ORALStimulants - Misc.CONCERTA 18MGTBCR,54MGTBCR,27MGTBCRORALCONCERTA 36MGTBCR ORALDAYTRANA TRANSDERMALFOCALIN (dexmethylphenidate hcl) ORALFOCALIN XR ORALMETADATE CD ORALMETADATE ER (methylphenidate hcl) ORALFormularyFormularyFormularyABCBrand Generic Brand Generic Brand GenericTier Tier Tier Tier Tier FJ3JJ*NFJJ*3*4424*3*3*44422QL 3ea/dayQL 1ea/dayQL 1ea/day4JNFJJ*4*JJ*LimitsQL 2ea/dayJ4J30DS30DS30DS3NF4PA, QL 3ea/day223QL 2ea/day223QL 1ea/day223QL 1ea/day233*332*2NF3*NFNF2*344*443*QL 2ea/dayQL 1ea/dayQL 2ea/dayQL 1ea/dayQL 1ea/day313142* Product Selection Penalty: You may be charged your copayment plus the difference in cost between the brand and genericdrugs. Please refer to pages 11 - 12 for a complete description of abbreviations.AL Age LimitB/D Medicare Part B vs. D GL Gender Limit J InjectableLD Limited DistributionNF Nonformulary PA Prior AuthorizationQL Quantity Limit S Specialty Tier ST Step Therapy30DS 30-Day Supply15 / www.healthnet.com

FormularyFormularyFormularyABCBrand Generic Brand Generic Brand GenericBRAND DRUG (generic drug)Tier Tier Tier Tier Tier TierMETHYLIN ORAL223PROVIGIL 100MGTABS ORAL324PROVIGIL 200MGTABS ORAL233RITALIN (methylphenidate hcl) ORAL2*12*13*2RITALIN LA 10MGCP24,20MGCP24,40MGCP24 ORAL 334RITALIN LA 30MGCP24 ORAL3NF4RITALIN SR (methylphenidate hcl) ORAL2*12*13*2AMEBICIDESAmebicidesYODOXIN 210MGTABS ORAL223YODOXIN 650MGTABS ORAL3NF4AMINOGLYCOSIDESAminoglycosidesAMIKIN (amikacin sulfate) INJECTIONJ*JJ*JJ*JGARAMYCIN (gentamicin sulfate) INJECTIONJ*JJ*JJ*JGENTAMICIN SULFATE INJECTIONJJJGENTAMICIN SULFATE INTRAVENOUSJJJGENTAMICIN SULFATE/0.9% SODIUM CHLORIDEJJJINTRAVENOUSGENTAMICIN SULFATE/SODIUM CHLORIDEJJJINTRAVENOUSHUMATIN (paromomycin sulfate) ORAL2*12*13*2ISOTONIC GENTAMICIN INTRAVENOUSJJJKANAMYCIN SULFATE INJECTIONJJJKANTREX INJECTIONJJJNEO-FRADIN ORAL223NEOMYCIN SULFATE ORAL223STREPTOMYCIN SULFATE INTRAMUSC.JJJTOBI INHALATION3NF4TOBRAMYCIN SULFATE ADD-VANTAGEJJJINTRAVENOUSTOBRAMYCIN SULFATE INJECTIONJJJTOBRAMYCIN SULFATE/SODIUM CHLORIDEJJJINTRAVENOUSANALGESICS - ANTI-INFLAMMATORYAnalgesics - Anti-inflammatory CombinationsLimitsPAPAQL 1ea/dayQL 2ea/day30DS30DS30DS30DS30DS30DS30DS30DS30DS30DSPA, B/D30DS30DS30DS* Product Selection Penalty: You may be charged your copayment plus the difference in cost between the brand and genericdrugs. Please refer to pages 11 - 12 for a complete description of abbreviations.AL Age LimitB/D Medicare Part B vs. D GL Gender Limit J InjectableLD Limited DistributionNF Nonformulary PA Prior AuthorizationQL Quantity Limit S Specialty Tier ST Step Therapy30DS 30-Day Supply16 / www.healthnet.com

BRAND DRUG (generic drug)THERAPROXEN ORALTHERAPROXEN-90 ORALAnti-TNF-alpha - Monoclonoal AntibodiesHUMIRA 20MG/0.4MLKIT SUBCUTANEOUSHUMIRA 40MG/0.8MLKIT SUBCUTANEOUSHUMIRA PEN SUBCUTANEOUSAntirheumatic AntimetabolitesRHEUMATREX (methotrexate sodium (antirheumatic))ORALGold CompoundsMYOCHRYSINE (gold sodium thiomalate)INTRAMUSC.RIDAURA ORALInterleukin-1 BlockersARCALYST SUBCUTANEOUSInterleukin-1 Receptor Antagonist (IL-1Ra)KINERET SUBCUTANEOUSNonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX (naproxen sodium) ORALANAPROX DS (naproxen sodium) ORALANSAID (flurbiprofen) ORALARTHROTEC 50 ORALARTHROTEC 75 ORALCATAFLAM (diclofenac potassium) ORALCELEBREX ORALCLINORIL (sulindac) ORALDAYPRO (oxaprozin) ORALDICLOFENAC SODIUM EC (diclofenac sodium) ORALEC-NAPROSYN (naproxen) ORALETODOLAC ER ORALETODOLAC ORALFELDENE (piroxicam) ORALFENOPROFEN CALCIUM ORALFLURBIPROFEN ORALINDOCIN IV INTRAVENOUSINDOCIN ORAL (indomethacin) ORALFormularyFormularyFormularyABCBrand Generic

Health Net Orange Prescription Drug Plans 1-800-806-8811, TTY 1-800-929-9955 CALIFORNIA for medical plans: Health Net Seniority Plus and Health Net Options Plus P.O. Box 10198 Van Nuys, CA 91410-0198 for health net orange, part d prescription drug plans and health net pearl private fee-for-service: