Prior Authorization Requirements
California
Medi-Cal LA-DHS PPGs
Effective July 9, 2026; updated July 28, 2026
The services, procedures, equipment and outpatient pharmaceuticals below apply to:
- Medi-Cal Los Angeles County Department of Health Services (LA-DHS) participating physician groups (PPGs)
These are subject to prior authorization (PA) requirements (unless noted as “notification” required only) and 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.
Medical necessity – Medical necessity must exist for any plan benefit to be a covered service whether a PA is required or not.
Eligibility rules and limitations – Providers are responsible for verifying member eligibility through the Health Net Medi-Cal Provider Services Center prior to providing care. 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, phone or online.
- Submit the request to Health Net - Prior Authorization unless stated differently in requirements listed below.
- The inpatient (PDF) or outpatient (PDF) Health Net Medi-Cal Prior Authorization Request 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 Prevent Prior Authorization Delays With These Submission Guidelines (PDF).
PA timelines –
If the request is for … | Submit prior authorization request: |
|---|---|
An elective in-patient or outpatient service or procedure. | As soon as the need for service is identified. |
A routine request or procedure. | At least seven calendar or 5 business days (whichever comes first) before a scheduled procedure. |
An urgent request or procedure. | 72 hours before a scheduled procedure. Emergency services do not require prior authorization. |
Providers should also refer to Limitations and Exclusions, in addition to Sensitive, Confidential or Other Services at the end of this requirements list, that do not require PA for Medi-Cal members.
Inpatient Services
Submit a prior authorization request to Health Net - Prior Authorization unless stated differently in requirements listed below.
Inpatient Services 1 | |
|---|---|
Hospitalization - Elective | Elective medical or surgical admissions to non-LA-DHS hospitals 2 Includes:
|
Hospitalization - Emergency | Notification required only Emergency hospitalizations and continuing stays at non-LA-DHS hospitals once emergency stabilization is complete Contact the Health Net Hospital Notification Unit |
Long-term care nursing facility admission | Contact the Health Net Hospital Notification Unit |
Skilled nursing facility (SNF) | All elective admissions to skilled nursing facilities |
1Medically necessary procedures performed during acute inpatient hospitalization are included under the inpatient PA (excluding experimental and investigational procedures). Medically necessary procedures performed in emergency situations do not require PA.
2Non-LA-DHS hospitals include hospitals and clinics in Antelope Valley.
Outpatient Procedures, Services or Equipment
Submit a prior authorization request to Health Net - Prior Authorization unless stated differently in requirements listed below.
OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT | |
|---|---|
All referrals to out-of-network providers (non-LA-DHS clinics or hospitals) | PA not required for self-referred services allowed under the Medi-Cal plan for family planning, pregnancy termination, HIV counseling and testing, immunizations at the local health department (LHD), and sexually transmitted infections (STIs) |
Ablative techniques for prostate tumors | Authorized by the Health Net Prior Authorization when provided outside of an LA-DHS facility |
Acupuncture |
|
Behavioral health (outpatient services) |
|
Bronchial thermoplasty | |
Dental anesthesia: Intravenous (IV) moderate sedation and deep sedation/general anesthesia | Authorized by the Health Net - Prior Authorization when provided outside of an LA-DHS facility |
Durable medical equipment (DME) – Pediatric | Members under age 21: All DME requires PA |
DME – Adult | Members ages 21 and older: The following DME requires PA:
|
Enteral nutrition products | |
Experimental/investigational services and new technologies | Includes, but is not limited to, those listed in the Investigational Procedures List (PDF) |
Gender reassignment services (transgender services) | Authorized by the Health Net - Prior Authorization when provided outside of an LA-DHS facility |
Genetic testing | |
Hospice | To initiate outpatient hospice services, the following documentation must be submitted to Health Net. Refer to Hospice Services Documentation Guide (PDF).
|
Hyperbaric oxygen therapy | |
Leg stent bridge | |
Neuro and spinal cord stimulators, including procedures | Authorized by the Health Net - Prior Authorization when provided outside of an LA-DHS facility |
Custom orthotics | |
Palliative care | |
Proprietary laboratory analyses | Includes the following CPT® codes: 0457U, 0459U, 0462U, 0468U, 0472U, 0577U, 0579U, 0591U, 0596U, 0598U, 0599U, 0614U, 0615U, 0636U, 0637U, 0638U, 0639U |
Prosthetics | |
Transplant |
|
Transportation | All non-emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS) (PDF)
Non-medical transportation (NMT) is available upon request by contacting Modivcare (rideshare, passenger car/sedan, taxi, public or private conveyance). Prior Authorization is not required. |
Unlisted services and procedures | Services or procedures without a specific code. |
Outpatient Pharmaceuticals (Submitted Under Medical Benefit)
Medications
- Authorized by Pharmacy Services
OUTPATIENT PHARMACEUTICALS (Submitted Under Medical Benefit) | |
|---|---|
Medications newly approved by the U.S. Food and Drug Administration (FDA) | May require prior authorization – Contact Pharmacy Services to confirm |
Self-injectables |
|
Testosterone therapy | |
- Authorized by Pharmacy Services
- Coram is Health Net's preferred infusion provider
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) | |
|---|---|
DRUG/THERAPY CLASS | |
Aflibercept agents | Examples include: Ahzantive®, EnzeevuTM, Eydenzelt®, Eylea®/Eylea HD, Opuviz™, Pavblu™, Yesafili™ |
Alpha-1 proteinase inhibitors | Examples include:
|
Bortezomib agents | Examples include:
|
Corticosteroid ophthalmic injections | Examples include:
|
Denosumab agents | Examples include:
|
Eculizumab agents | Examples include:
|
Exon-skipping therapies | Examples include:
|
Gene therapy, includes CAR-T therapy | Examples include:
*CAR-T therapy |
GnRH agonists | Examples include:
Camcevi/Camcevi ETM: no PA required for urology/hematology/oncology |
Hereditary angioedema (HAE) agents | Examples include:
|
Intravenous (IV) iron agents | Examples include: Injectafer®, Monoferric® |
Immune globulin agents | Examples include:
|
Lysosomal storage disorders | Examples include:
|
Natalizumab agents | Examples include:
|
Omalizumab agents | Examples include:
|
PD-1/PD-L1 inhibitors | Examples include:
|
Pemetrexed agents | Examples include: Alimta®, AxtleTM, Pemfexy TM, Pemrydi RTU® |
Pulmonary arterial hypertension (PAH) agents | Examples include:
|
Ranibizumab agents | Examples include:
|
Tocilizumab agents | Examples include:
|
Ustekinumab agents | Examples include:
|
Viscosupplementation agents | Examples include:
|
The following medications require prior authorization from the Pharmacy Services when provided outside of LA-DHS facility
For the reference product, all generics or biosimilar drugs will require a prior authorization
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) | ||||
|---|---|---|---|---|
Abrilada™ Adakveo® Adcetris® Adzynma™ Akynzeo® Aliqopa™ Amtagvi™ Anktiva® Amvuttra® Aphexda® Aristasda® Arzerra® Asparlas™ Azedra® Beleodaq® Benlysta® Beovu® Besponsa® Bizengri® Blenrep® Blincyto® Botox® Briumvi® Cablivi® Ceprotin® (ages 0–20 only) Cimzia® Cinqair® Columvi™ Cortrophin® Cosela™ Cosentyx® Crysvita® Cyramza® Danyelza® Darzalex®/Darzalex Faspro® Datroway® Daxxify® DDAVP (ages 0–20 only)Dupixent® | Durysta™ Dysport® Elahere™ Elrexfio™ Elzonris® Empaveli™ Empliciti® Emrelis™ Enjaymo™ Entyvio™ Epkinly™ Erbitux® Erwinaze® (ages 0–20 only) Evenity® Evkeeza™ Exdensur® Fasenra™ Faslodex® Folotyn® Furoscix® Fyarro™ Gamifant® Gazyva® Givlaari Grafapex™ H.P. Acthar® Gel Halaven® Hepzato® iDose® TR (implant) Ilumya® Ilaris® Imaavy™ Imdelltra™ Imjudo® Inlexzo™ Izervay™ Jelmyto™ Jesduvroq™ Jevtana® Jobevne™ Ketalar® Kimmtrak® Kisunla® Krystexxa® Kyprolis® Lantidra™ Lemtrada® | Leqembi™ Leqvio® Leukine® Levoleucovorin (Khapzory™) Lumoxiti® Lunsumio™ Lutathera® Lymphir™ Lynozyfic™ Macugen® Margenza™ Marqibo® Monjuvi® Mozobil® Mylotarg™ Myobloc® Myozyme® Niktimvo™ Novantrone® Nplate® Nucala Nulibry™ Nulojix® Ocrevus™ Ocrevus Zunovo® Ohtuvayre™ Omisirge® Omvoh™ Oncaspar® Onpattro™ Orencia® Oxlumo™ Padcev® Paliperidone palmitate Panhematin® Parsabiv® Perjeta® Phesgo® PiaSky® Pluvicto® Polivy™ Poteligeo® Prevymis™ Provenge® Qalsody™ Radicava™ | Radiesse® Reblozyl® Rebyota™ Rethymic® (implant) Revcovi™ Rybrevant®/ Rybrevant Faspro™ Rylaze™ Ryplazim® Ryoncil® Rystiggo® Rytelo® Sandostatin® LAR kit Saphnelo™ Sarclisa® Scenesse® Sculptra® Signifor® LAR Simponi Aria® Sinuva® Skyrizi® Somatuline® Depot Sotradecol® Spevigo® Spinraza™ SpravatoTM Sustol® Syfovre™ Synagis® Synribo® Talvey™ Tecvayli™ Tepezza® Testopel® Tezspire® Thyrogen® Tivdak™ Tremfya® Trodelvy® | Tzield™ Ultomiris™ Unituxin® Uplizna® Vabysmo® Valstar® Vectibix® Veopoz™ Vidaza® Visudyne® Vyalev™ Vyepti™ Vyjuvek® Vykoura™ Vyloy® Vyvgart® Vyvgart Hytrulo Vyxeos (ages 0-20 only) Xeomin® Xiaflex® Yartemlea® Yervoy® Zaltrap® Zemdri™ Zepzelca™ Zevaskyn™ Ziihera® Zilretta™ Zinplava™ Zulresso™ Zusduri™ Zynlonta® |
- Biosimilars require prior authorization
- Preferred biosimilars are required in lieu of branded drugs
- Authorized by 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 – 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®, NypoziTM, Releuko® |
|
Infliximab agents – Remicade® | Avsola®, Inflectra®, Renflexis® |
Pegfilgrastim agents –Armlupeg®, Fylnetra®, Neulasta®, Neulasta OnPro®, Nyvepria®, RolvedonTM, RyzneutaTM, Stimufend® , Ziextenzo® | Fulphila®, Udenyca®, Udenyca Onbody |
Rituximab agents – Riabni®, Rituxan®, Rituxan HycelaTM | Ruxience®, Truxima® (no PA required for hematology/oncology indications) |
Trastuzumab agents – Enhertu®, Herceptin®, Herceptin HylectaTM, HercessiTM, Herzuma®, Kadcyla®, Ontruzant® | Kanjinti®, Ogivri®, TrazimeraTM |
CalAIM Benefits and Services Requiring Authorization
Submit a prior authorization request to Health Net
CALAIM BENEFITS AND SERVICE | |
|---|---|
Community Supports non-benefit services
|
|
CalAIM Benefits
| |
Limitations and Exclusions
- CCS-eligible conditions are carve-out services not covered by Health Net and require prior authorization from the local CCS office.
- CCS services must be provided by CCS-paneled providers and at CCS approved facilities.
- Any services related to CCS -eligible medical conditions must be approved by the CCS program. Refer to the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS, Chapter 4, Medical Eligibility, Article 4, available online at www.calregs.com.
- Routine laboratory and radiology services must be performed at a Health Net participating facility.
- Specialty mental health services and select substance use disorder services are covered by the county mental health program. If coordination assistance with the county mental health program is needed, contact Health Net Medi-Cal Member Services.
- Cosmetic surgery is not a benefit of the Medi-Cal program. Cosmetic surgery requests are reviewed for possible reconstructive benefits, as well as medical necessity, using the Department of Health Care Services (DHCS) definition of cosmetic surgery.
- Authorizations for services commonly included in the local educational agency (LEA) carve-out are referred to the local school district. These include speech therapy, occupational therapy and audiology services for children ages three and over, and psychological testing for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD).
- A member or provider is not required to obtain prior authorization for NEMT services if the member is being transferred from an emergency room to an inpatient setting, or from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility or imbedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, or any other appropriate inpatient acute psychiatric facilities.
Sensitive, Confidential or Other Services
Below are sensitive, confidential and other services that do not require PA for Medi-Cal members.
Referral or PA is not required for the following sensitive services, and members may obtain them from any qualified in- network or out-of-network provider:
- Minor consent services – which include treatment for the following:
Under age 12
- Pregnancy and pregnancy related services, including abortion services
- Family planning services, such as contraception services (e.g., birth control)
- Sexual assault services
Age 12 and older - under 18
- Pregnancy and pregnancy related services, including abortion services
- Family planning services, such as contraception services (e.g., birth control)
- Sexual assault services
- Infectious, contagious, or communicable disease diagnosis and treatment, including for HIV/AIDS
- Sexually transmitted infection (STI) prevention (or infections), diagnosis, and treatment for STIs like syphilis, gonorrhea, chlamydia, and herpes simplex
- Substance use disorder (SUD) treatment for drug and alcohol abuse treatment and counseling
- Outpatient mental health treatment and counseling. Minors may obtain outpatient mental health services, if in the opinion of the attending professional person determines that the minor is mature enough to participate intelligently in their health care pursuant to Family Code section 6924.
- Intimate partner violences services
- Adult sensitive care services:
- Family planning and birth control including sterilization for adults 21 and older.
- Pregnancy testing and counseling and other pregnancy related services.
- HIV/AIDS prevention and testing.
- Sexually transmitted infections prevention testing and treatment.
- Sexual assault care.
- Outpatient abortion services.
Referral or PA is not required for Comprehensive Perinatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers. Refer to the CPSP website
Other services not requiring PA:
- Basic prenatal maternal and preventive services and care as defined by the most current clinical standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) with a participating network obstetrician.
- Obstetrical/gynecological (OB/GYN) services from a participating provider.
- California Prenatal Screening (PNS) services performed by participating providers.
- California Newborn Screening Program administered by California Department of Public Health (CDHP) up to one year of age.
- Certified Nurse Midwife (CNM) or Licensed Midwife (LM) coverage of basic prenatal, maternal, and preventive services and care (ACOG/CPSP) (in and out of network.
- Lactation consultation for pregnant and postpartum members.
- Breast pumps: non-hospital grade (manual and electric) from participating providers.
- Outpatient abortion services (in or out of network).
- Family planning and related services: contraceptive services, laboratory procedures, radiology, and drugs associated with family planning procedures. Pregnancy testing and counseling. Sexually transmitted infection prevention, counseling, screening, testing, diagnosis and treatment services. HIV counseling and testing and Cervical cancer screening.
- Preventive services from a participating provider.
- Services for emergency medical conditions.
- Specialist referral (initial referral to participating specialist).
- Urgently needed services when the member is outside of his or her county.
- MOA 638 Indian Health Service facilities.
- American Indian/Alaska Native member may receive services from an out of network Indian Health Care Provider.
- Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (FDA approved).
- COVID-19 diagnostic and screening testing.
- Services that are rendered under the Children and Youth Behavioral Health Initiative fee schedule
- Initial mental health and substance use disorder assessments.
- Adult preventive immunizations from a participating physician or other provider.
- Second opinion from a participating physician or other provider.