Prior Authorization Requirements
California
Commercial
Effective August 1, 2024
The services, procedures, equipment and outpatient pharmaceuticals below apply to:
- Direct Network1 HMO (including Ambetter HMO) and Point of Service (POS) Tier 1
- POS Tiers 2 and 3 (Elect, Select and Open Access)
- Ambetter (Amb.) HMO participating physician groups (PPGs)
- PPO (including Amb.) and out-of-state PPO
These are subject to prior authorization (PA) requirements (unless noted as "notification" required only) if an “X” is included under the applicable line of business. If “X” is not present, PA may not be required or the service, procedure, equipment or outpatient pharmaceutical may not be a covered benefit. PA is guaranteed only as of the time of access to this prior authorization requirements page.
Member questions – If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.
Pre-Auth Check Tool for individual plans – To confirm whether a specific code requires authorization, go to: IFP Ambetter HMO or IFP Ambetter PPO and follow the prompts.
Medical necessity – Medical necessity must exist for any plan benefit to be a covered service whether a PA is required or not.
Services that require PA vs. covered services – This PA list is not intended to be a list of covered services. The member’s Evidence of Coverage (EOC) provides a complete list of covered services. EOCs may be available online to members on the Health Net website (IFP, Small Group, Large Employer Groups) or by requesting them from the Health Net Provider Services Center.
Eligibility rules and limitations – Refer to the member’s Health Net identification (ID) card to confirm product type before proving care. Then verify member eligibility through the Health Net Provider Services Center. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply – all services, procedures, equipment and outpatient pharmaceuticals are subject to benefit plan coverage limitations.
Submit a PA request –
- Send the request via fax or online to Health Net unless stated differently in requirements listed below.
- The Health Net Request for Prior Authorization form must be completed in its entirety.
- Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request.
- For more submission instructions, see 'Avoid Processing Delays for Prior Authorization Requests with These Guidelines.' (PDF).
If the request is for … | Submit prior authorization request: |
|---|---|
An elective in patient or outpatient services or procedures. | As soon as the need for service is identified. |
A routine request or procedure. | At least five business days before a scheduled procedure. |
An urgent request or procedure. | 72 hours before a scheduled procedure. Emergency services do not require prior authorization. |
Services outside of California – PPO plans that include travel benefits and out-of-state PPO plans: Inpatient services, medical oncology and transplant services require prior authorization. Verify member eligibility through the Health Net Provider Services Center prior to providing care. Services provided within California follow the requirements and directions below.
Select lines of business are abbreviated as follows: Ambetter HMO PPGs is Amb. HMO PPGs, POS Tiers 1, 2 and 3 are POS T1, POS T2, POS T3; out of-state PPO is OOS PPO. Ambetter HMO utilizes the CommunityCare network.
Inpatient Services
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Inpatient Service | HMO, POS T1 | Amb. HMO PPGs | POS T2, POS T3 | PPO, OOS PPO |
|---|---|---|---|---|
Behavioral health or substance abuse facility Authorized by the Behavioral Health Team or check member’s ID card for contact information | X | X | X | X |
Hospice | X | X | X | X |
Hospital
| X | X | X | X |
Skilled nursing facility | X | X | X | X |
Urgent/emergent admission
| X | X | X | X |
Outpatient Services
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Outpatient Service | HMO, HSP, POS T1 | Amb. HMO PPGs | POS T2, POS T3 | EPO, PPO, OOS PPO, Flex Net |
|---|---|---|---|---|
Ablative techniques for treating Barrett’s esophagus and for treatment of primary and metastatic liver malignancies | X | X | X | X |
Ambulance
| X | X* | X | X |
Bariatric procedures
| X | X* | X | X |
Behavioral health and substance abuse Authorized by the Behavioral Health Team other than office visits including:
| X | X | X | X |
Bronchial thermoplasty | X | X | X | |
Capsule endoscopy | X | X* | X | X |
Cardiovascular procedures Authorized by TurningPoint Healthcare Solutions, LLC. Includes:
| X | |||
Chiropractic care and Acupuncture visits
| X | X | X | X |
Clinical trials | X | X | X | X |
Dermatology (in-office procedures) Includes:
| X | X* | X | X |
Diagnostic procedures Authorized by Evolent Specialty Services, Inc. (Evolent) Advanced imaging:
Cardiac imaging:
| X | X | X | X |
Drug testing PA required for all quantitative tests for drugs of abuse | X | X | X | |
Durable medical equipment (DME) Includes:
| X | X | X | X |
Ear, nose, throat (ENT) services Authorized by TurningPoint Healthcare Solutions, LLC
| X | |||
Ear, nose, throat (ENT) services Authorized by Health Net Includes:
| X | X* | X | |
Enhanced external counterpulsation (EECP) | X | X* | X | X |
Experimental/investigational services and new technologies Includes, but is not limited to, those listed in the Investigational Procedures List | X | X | X | X |
Gender reassignment services (Transgender services) | X | X* | X | X |
Genetic testing Includes counseling | X | X* | X | X |
Maternity Notification required only at time of first prenatal visit | X | X | X | X |
Neuropsych testing Authorized by the Behavioral Health Team or Health Net. Check member’s ID card for contact information | X | X* | X | X |
Orthognathic procedures Includes:
| X | X* | X | X |
Orthotics Custom-made orthotics | X | X | X | X |
Proprietary laboratory analyses Includes the following CPT® codes: 0457U, 0459U, 0462U, 0468U, 0472U | X | X | X | X |
Prosthetics Applies to items exceeding $2,500 in billed charges | X | X | X | X |
Radiation therapy For HMO, PPO, OOS PPO – Authorized by eviCore healthcare For POS T1, T2, T3 – Authorized by Health Net; limited to:
| X | X* | X | X |
Reconstructive and cosmetic surgery, services and supplies Surgery, services, and supplies, including, but not limited to:
| X | X* | X | X |
Referrals to nonparticipating providers
| X | X | X | |
Spinal surgery
| X | X* | X | X |
Therapy Requires PA after 12 combined visits, including home setting
| X | X* | X | X |
Transplant
| X | X | X | X |
Trigger point and sacroiliac (SI) joint injections | X | X* | X | X |
Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP Surgical procedure | X | X* | X | X |
Vestibuloplasty Surgical procedure | X | X* | X | X |
Wound care Including but not limited to:
| X | X* | X | X |
*Subject to PA from the Health Net CommunityCare PPG.
Outpatient Pharmaceuticals (Submitted Under Medical Benefit)
Medications
- Authorized by Health Net Pharmacy Services
- Outpatient pharmaceuticals require prior authorization for all commercial ines of business: HMO, POS T1, POS T2, POS T3, Amb. HMO PPGs, PPO and OOS PPO
Outpatient Pharmaceuticals (Submitted under medical benefit) | |
|---|---|
Hemophilia factors | AcariaHealth™ is Health Net’s preferred provider |
Medications newly approved by the U.S. Food and Drug Administration (FDA) | May require prior authorization – Contact Health Net Pharmacy Services to confirm |
Self-injectables | For a list of self-injectables, refer to the DOFR crosswalk |
Testosterone therapy | |
- Authorized by Health Net Pharmacy Services
- Coram is Health Net's preferred infusion provider
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) | |
|---|---|
DRUG/THERAPY CLASS | |
Gene therapy, includes CAR-T therapy | Examples include:
*CAR-T therapy |
GnRH agonists | Examples include:
Authorization required for non-oncology/non-urology only:
|
Hereditary angioedema (HAE) agents | Examples include:
|
Intravenous (IV) iron agents | Examples include:
|
Immune globulin agents | Examples include:
|
Lysosomal storage disorders | Examples include:
|
Pemetrexed agents | Examples include:
|
Pulmonary arterial hypertension (PAH) agents | Examples include:
|
Ranibizumab agents | Examples include:
|
Viscosupplementation agents | Examples include:
|
- The following medications require prior authorization from the Health Net Pharmacy Services
- For the reference product, all generics or biosimilar drugs will require a prior authorization
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) | ||||
|---|---|---|---|---|
Abrilada™ Actemra® Adakveo® Adcetris® Adzynma™ Akynzeo® Aliqopa™ Amondys 45™ Amvuttra® Aphexda® Aralast® Arzerra® Asparlas™ Azedra® Bavencio® BCG Intravesical Beleodaq® Benlysta® Beovu® Besponsa® Bevacizumab agents Blincyto® Botox® Briumvi® Cablivi® Casgevy™ Cimzia® Cinqair® Columvi™ Cortrophin® Cosela™ Cosentyx® Crysvita® Cyramza® Danyelza® Darzalex® Daxxify® Dupixent® Durysta™ Dysport® Elahere™ | Elrexfio™ Elzonris® Empaveli™ Empliciti® Enjaymo™ Entyvio™ Epkinly™ Erbitux® Evenity® Evkeeza™ Exondys 51™ Eylea®/Eylea HD Fasenra™ Faslodex® Folotyn® Fyarro™ Gamifant® Givlaari Glassia™ H.P. Acthar® Gel Halaven® iDose®TR (implant) Ilaris® Ilumya® Iluvien® Imfinzi® Imjudo® Inflectra™ Izervay™ Jelmyto™ Jemperli® Jesduvroq™ Jevtana® Keytruda® Kimmtrak® Krystexxa® Kyprolis® Lemtrada® Leqembi™ Leqvio® Levoleucovorin (Fusilev®, Khapzory™) | Libtayo® Loqtorzi™ Lumoxiti® Lunsimo™ Lutathera® Lyfgenia™ Macugen® Margenza™ Marqibo® Monjuvi® Mozobil® Mylotarg™ Myobloc® Myozyme® Novantrone® Nplate® Nucala Nulibry™ Nuzyra® Ocrevus™ Omvoh™ Oncaspar® Onpattro™ Opdivo® Opdualag™ Orencia® Oxlumo™ Ozurdex® Padcev® Panhematin® Parsabiv® Pepaxto® Perjeta® Phesgo® Polivy™ Poteligeo® Prevymis™ Prolastin® Prolia® Provenge® | Qalsody™ Radicava™ Radiesse® Reblozyl® Rebyota™ Renflexis™ Retisert® Revcovi™ Rybrevant™ Rylaze™ Ryplazim® Rystiggo® Sandostatin® LAR kit Saphnelo™ Sarclisa® Scenesse® Sculptra® Sensipar® Signifor® LAR Simponi Aria® Sinuva® Skyrizi® Soliris® Somatuline® Depot Sotradecol® Spevigo® Spinraza™ Spravato™ Stelara® Sunlenca® Sustol® Syfovre™ Synagis® Synribo® Talvey™ Tecentriq® Tecvayli™ Tepezza® Testopel® Tezspire® | Tivdak™ Tofidence™ Trodelvy® Trogarzo™ Tyruko® Tysabri® Tzield™ Ultomiris™ Unituxin® Uplizna® Vabysmo® Valstar® Vectibix® Ventavis® Veopoz™ Vidaza® Viltepso® Visudyne® Vyepti™ Vyjuvek® Vyondys 53® Vyvgart® Vyvgart Hytrulo Wezlana™ Xenpozyme® Xeomin® Xgeva® Xiaflex® Xipere® Xolair® Yervoy® Yutiq™ Zaltrap® Zemaira® Zemdri™ Zepzelca™ Zilretta™ Zinplava™ Zulresso™ Zynlonta® Zynyz™ |
- Biosimilars require prior authorization
- Preferred biosimilars are required in lieu of branded drugs
- Authorized by Health Net Pharmacy Services
- Must try preferred products prior to non preferred approval. Please refer to the drug specific policy for complete list of preferred products
OUTPATIENT PHARMACEUTICALS - BIOSIMILARS | |
|---|---|
NON-PREFERRED | PREFERRED |
Bevacizumab agents – Alymsys®, Avastin®, Vegzelma® (no longer requires PA for ophthalmologists) | Mvasi®, ZirabevTM (no PA required for ophthalmologists) |
Erythropoiesis-stimulating agents (ESA) –Aranesp®, Epogen®, Mircera®, Procrit® | RetacritTM (PA not required for Retacrit when administered/provided under the medical benefit) |
Filgrastim agents – Granix®, Neupogen®, Releuko® |
|
Infliximab agents – including Remicade® | Inflectra®, Renflexis® |
Pegfilgrastim agents – Fulphila®, Fylnetra®, Neulasta®, Neulasta Onpro®, Nyvepria®, RolvedonTM, Ryzneuta TM, Stimufend® | Udenyca®, Udenyca Onbody, Ziextenzo® |
Rituximab agents – Riabni®, Rituxan®, Rituxan HycelaTM, Riabni® | Ruxience®, Truxima® (no PA required for hematology/oncology indications) |
Trastuzumab agents – Enhertu®, Herceptin®, Herceptin HylectaTM, Herzuma®, Kadcyla®, Ontruzant® | Kanjinti®, Ogivri®, TrazimeraTM |