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Health Net Prior (Rx) Authorization Form

Health Net Prior (Rx) Authorization Form

Updated July 27, 2023

A Health Net prior authorization form is a document that medical offices will use when requesting coverage of a patient’s prescription. Certain insurance policies may not cover all prescriptions, usually, those that are highly expensive, thus approval from Health Net must be received before a prescription can be written. This form needs to be filled in by the medical staff and submitted to Health Net for review.

  • Arizona DME Fax Request: DME 1 (800) 916-8996
  • Arizona General PA: 1 (800) 840-109
  • California Request: Fax 1 (800) 793-4473 or call 1 (800) 672-2135
  • Oregon/WA Medicare Fax Request: 1 (866) 295-8562
  • Oregon/WA Commercial Fax Request: 1 (800) 495-1148