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Prior Authorization Requirements

California
Commercial

Effective March 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 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 may not be a covered benefit. PA is guaranteed only as of the time of access to this prior authorization requirements page. Providers are responsible for verifying member eligibility through the Health Net Provider Services Center prior to providing care. Even if a service or supply is authorized, eligibility rules and benefit limitations will still apply.

For Individual plans, to confirm whether a specific code requires authorization go to: IFP Ambetter HMO or IFP Ambetter PPO and follow the prompts.

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 or by requesting them from the Health Net Provider Services Center.

Submit a prior authorization request to Health Net unless stated differently in requirements listed below. Refer to the member’s Health Net identification (ID) card to confirm product type. Requests should be submitted to Health Net via fax or online. The Health Net Request for Prior Authorization form must be completed in its entirety and include sufficient clinical information or notes to support medical necessity for services that are requested.

When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All services, procedures, equipment and outpatient pharmaceuticals are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not PA is required.

Services provided pursuant to a CARE agreement or CARE plan approved by a court do not require prior authorization.

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.

1Direct Network refers to Health Net’s directly contracting network for HMO, Ambetter HMO and POS Tier 1 products.

If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.

Services outside of California – PPO plans that include travel benefits and out-of-state PPO plans: Inpatient services and medical oncology 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.

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

  • Notification required only, as soon as possible, but no later than 24 hours or by the next business day
  • Send notification to Hospital Notification Unit
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

  • Non-emergency air transportation
  • Non-emergency ground transportation

X

X*

X

X

Bariatric procedures

  • Surgical procedure
  • Bariatric surgeries must be performed through Health Net’s designated bariatric specialty network

X

X*

X

X

Behavioral health and substance abuse

Authorized by the Behavioral Health Team other than office visits including:

  • Applied behavioral analysis (ABA) and other forms of behavioral health treatment (BHT) for autism and pervasive developmental disorders
  • Electroconvulsive therapy (ECT)
  • Half-day partial hospitalization
  • Intensive outpatient program (IOP)
  • Neuropsychological testing ordered by a psychiatrist
  • Partial hospital program or day hospital (PHP)
  • Psychological testing
  • Transcranial magnetic stimulation (TMS)

X

X

X

X

Bronchial thermoplasty

X

X

X

Capsule endoscopy

X

X*

X

X

Cardiovascular procedures

Authorized by TurningPoint Healthcare Solutions, LLC.

Includes:

  • Arterial procedures
  • Coronary angioplasty/stenting
  • Coronary artery bypass grafting
  • Implantable cardioverter defibrillator (ICD)
  • ICD revision or removal
  • Leadless pacemaker
  • Left atrial appendage (LAA) occluders
  • Loop recorder
  • Non-coronary angioplasty/stenting
  • Pacemaker
  • Pacemaker revision or removal
  • Valve replacement
  • Wearable cardiac defibrillator (WCD)

X

Chiropractic care and Acupuncture visits

X

X

X

X

Clinical trials

X

X

X

X

Dermatology (in-office procedures)

Includes:

  • Chemical exfoliation, electrolysis
  • Dermabrasion/chemical peel
  • Laser treatment
  • Skin injections and implants

X

X*

X

X

Diagnostic procedures

Authorized by National Imaging Associates, Inc. (NIA)

Advanced imaging:

  • Computed tomography (CT)/computed tomography angiography (CTA)
  • Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA)
  • Positron emission tomography (PET) scan

Cardiac imaging:

  • Coronary computed tomography angiography (CCTA)
  • Myocardial perfusion imaging (MPI)
  • Multigated acquisition (MUGA) scan

X

X

X

X

Drug testing

PA required for all quantitative tests for drugs of abuse

X

X

X

Durable medical equipment (DME)

Includes:

  • BiLevel positive airway pressure (BiPAP); refer members to Apria Healthcare
  • Bone growth stimulator
  • Continuous glucose monitoring
  • Continuous positive airway pressure (CPAP); refer members to Apria Healthcare
  • Custom-made items including custom wheelchairs
  • Hospital beds and mattresses
  • Power wheelchairs
  • Scooters
  • Ventilators

X

X

X

X

Ear, nose, throat (ENT) services

Authorized by TurningPoint Healthcare Solutions, LLC

Includes:

  • Choanal atresia
  • Cochlear device (hearing)
  • Fistula repair
  • Laryngoscopy, laryngoplasty
  • Nasal, sinus endoscopy
  • Polyp excision
  • Rhinoplasty, septoplasty, vestibular stenosis repair
  • Thyroidectomy, parathyroidectomy
  • Tonsillectomy, adenoidectomy
  • Tympanostomy, tympanoplasty, myringotomy

X

Ear, nose, throat (ENT) services

Authorized by Health Net

Includes:

  • Balloon sinuplasty
  • Cochlear implants
  • Nasal surgery, such as rhinoplasty or septoplasty

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

Implantable pain pumps

Authorized by TurningPoint Healthcare Solutions, LLC

X

X*

X

X

Joint surgeries

Authorized by TurningPoint Healthcare Solutions, LLC

X

X*

X

X

Maternity

Notification required only at time of first prenatal visit

X

X

X

X

Neuro and spinal cord stimulators

Authorized by TurningPoint Healthcare Solutions, LLC

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:

  • TMJ treatment
  • Surgical procedure

X

X*

X

X

Orthotics

Custom-made orthotics

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:

  • Intensity modulated radiation therapy (IMRT)
  • Neutron beam therapy
  • Proton beam therapy
  • Stereotactic radiosurgery and stereotactic body radiotherapy (SBRT)

X

X*

X

X

Reconstructive and cosmetic surgery, services and supplies

Surgery, services, and supplies, including, but not limited to:

  • Bone alteration or reshaping, such as osteoplasty
  • Breast reduction and augmentation except when following a mastectomy (includes for gynecomastia or macromastia)
  • Dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures. Cleft palate includes cleft palate, cleft lip or other craniofacial anomalies associated with cleft palate
  • Excision, excessive skin and subcutaneous tissue (including lipectomy and panniculectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas
  • Eye or brow procedures, such as blepharoplasty, brow ptosis or canthoplasty
  • Gynecologic or urology procedures, such as clitoroplasty, labioplasty, vaginal rejuvenation, scrotoplasty, testicular prosthesis, and vulvectomy
  • Hair electrolysis, transplantation or laser removal
  • Lift, such as arm, body, face, neck, thigh
  • Liposuction
  • Otoplasty
  • Penile implant
  • Treatment of varicose veins
  • Vermilionectomy with mucosal advancement

X

X*

X

X

Referrals to nonparticipating providers

  • Applies to HMO, Amb. HMO PPGs, POS T1
  • Does not apply to POS T2, POS T3, PPO, OOS PPO

X

X

X

Sleep studies

Authorized by eviCore healthcare

X

X*

X

Spinal surgery

X

X*

X

X

Therapy

Requires PA after 12 combined visits, including home setting

  • Physical therapy
  • Occupational therapy
  • Speech therapy

X

X*

X

X

Transplant

  • Fax requests to the Transplant Team
  • All transplant evaluations and procedures, including, but not limited to, evaluation, transplant consult visits, donor search, and transplant procedure
  • Transplants must be performed through Health Net’s designated transplantation specialty network

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:

  • Negative pressure wound treatment, low-frequency ultrasound
  • Skin substitutes and biologicals
  • Wound debridement – authorization required after 12 sessions per year

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
Outpatient Pharmaceuticals (Submitted Under Medical Benefit)

DRUG/THERAPY CLASS

Gene therapy, includes CAR-T therapy
Examples include:
  • Abecma®*, Adstiladrin®, Breyanzi®*, Carvykti®*, ElevidysTM, Hemgenix®, KymriahTM*, LuxturnaTM, Skysona®, TecartusTM*, YescartaTM*, Zynteglo®, Zolgensma®

          *CAR-T therapy

GnRH agonists

Examples include:

  • Eligard®, Fensolvi®, Lupron Depot®, Lupron Depot-Ped®, Triptodur®, Zoladex®

Authorization required for non-oncology/non-urology only:

  • Eligard, Lupron Depot, Zoladex

Hereditary angioedema (HAE) agents

Examples include:

  • Berinert®, Cinryze®, Firazyr®, Haegarda®, Kalbitor®, Ruconest®, Takhzyro®
  • Preferred: Firazyr and Haegarda. See self-injectables
Intravenous (IV) iron agents

Examples include:

  • Feraheme®, Injectafer®, Monoferric®, Triferic®/Triferic AVNU

Immune globulin agents

Examples include:

  • Intravenous immunoglobulin (IVIG),  Asceniv®, Bivigam®, Cuvitru®, Flebogamma®, Gammagard® Liquid, Gammagard® S/D, GammakedTM, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, Xembify®

Lysosomal storage disorders

Examples include:

  • Aldurazyme®, Cerezyme®, Elaprase®, Elelyso®, Fabrazyme®, Kanuma®, Lumizyme®, Naglazyme®, Vimizim®, Vpriv®
Pemetrexed agents

Examples include:

  • Alimta® (no PA for generic), PemfexyTM and other generic
Pulmonary arterial hypertension (PAH) agents

Examples include:

  • PDE-5 inhibitors: Revatio®
  • Prostacylin analogues/receptor agonist injection: Flolan®, Remodulin®, Veletri®
  • Prostacylin analogues (PCA) inhalation: Tyvaso®, Ventavis®

Ranibizumab agents

Examples include:

  • CimerliTM, Lucentis®, Susvimo™

Viscosupplementation agents

Examples include:

  • Euflexxa®, Gelsyn-3TM, GenVisc® 850, Hyalgan®, Supartz FX TM, Synojoynt TM, Triluron TM, TriVisc TM, VISCO-3 TM, Durolane, Gel-One®, Hymovis®, Orthovisc®, Monovisc®, Synvisc®, Synvisc One®
  • 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)

Actemra®

Adakveo®

Adcetris®

Aduhelm™

Akynzeo®

Aliqopa™

Amondys 45™

Amvuttra®

Aralast®

Asparlas™

Azedra®

Bavencio®

BCG Intravesical

Beleodaq®

Beovu®

Besponsa®

Bevacizumab agents

Blenrep

Blincyto®

Botox®

Brineura™

Briumvi®

Cablivi®

Cimzia®

Cinqair®

Cortrophin®

Cosela™

Crysvita®

Cyramza®

Danyelza®

Darzalex®

Dupixent®

Durysta™

Dysport®

Elahere™

Elzonris®

Empaveli™

Empliciti®

Enjaymo™

Entyvio™

Epkinly™

Erbitux®

Evenity®

Evkeeza™

Exondys 51™

Eylea®

Fasenra™

Faslodex®

Folotyn®

Fyarro™

Gamifant®

Givlaari

Glassia™

H.P. Acthar®Gel

Halaven®

Histrelin acetate

Ilaris®

Iluvien®

Ilumya®

Imfinzi®

Imjudo®

Inflectra™

Jelmyto™

Jemperli®

Jesduvroq™

Jevtana®

Keytruda®

Kimmtrak®

Krystexxa®

Kyprolis®

Lemtrada®

Leqembi™

Leqvio®

Levoleucovorin (Fusilev®, Khapzory™)

Libtayo®

Lumoxiti®

Lutathera®

Macugen®

Margenza™

Marqibo®

Mepsevii™

Monjuvi®

Mozobil®

Mylotarg™

Myobloc®

Myozyme®

Nexviazyme®

Nplate®

Nucala

Nulibry™

Nuzyra®

Ocrevus™

Oncaspar®

Onpattro™

Opdivo®

Opdualag™

Orencia®

Oxlumo™

Ozurdex®

Padcev®

Panhematin®

Parsabiv®

Pepaxto®

Perjeta®

Phesgo®

Polivy™

Poteligeo®

Prevymis™

Probuphine®

Prolastin®

Prolia®

Provenge®

Qalsody™

Radicava™

Radiesse®

Reblozyl®

Rebyota™

Renflexis™

Retisert®

Revcovi™

Rybrevant™

Rylaze™

Ryplazim®

Sandostatin®LAR kit

Saphnelo™

Sarclisa®

Scenesse®

Sculptra®

Sensipar®

Simponi Aria®

Sinuva®

Skyrizi®

Soliris®

Somatuline®Depot

Sotradecol®

Spevigo®

Spinraza™

Spravato™

Stelara®

Sunlenca®

Sustol®

Syfovre™

Synagis®

Synribo®

Tecentriq®

Tecvayli™

Tepezza®

Testopel®

Tezspire®

Tivdak™

Trogarzo™

Tysabri®

Tzield™

Ultomiris™

Uplizna®

Vabysmo®

Vectibix®

Ventavis®

Vidaza®

Viltepso®

Visudyne®

Vyepti™

Vyondys 53®

Vyvgart®

Xenpozyme®

Xeomin®

Xgeva®

Xiaflex®

Xipere®

Xolair®

Yervoy®

Yutiq™

Zaltrap®

Zemaira®

Zemdri™

Zepzelca™

Zilretta™

Zinplava™

Zulresso™

Zynlonta®

Zynteglo®

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

Filgrastim agents – Granix®, Neupogen®, Releuko®

Nivestym®, Zarxio® (Zarxio preferred. If not tolerated, use Nivestym)

Infliximab agents – including Remicade®

Inflectra®, Renflexis®

Pegfilgrastim agents – Fulphila®, Fylnetra®, Neulasta®, Neulasta Onpro®, Nyvepria®, RolvedonTM, Stimufend®

Udenyca®, 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

Last Updated: 05/10/2024