Prior Authorization Requirements
California
Medi-Cal LA-DHS PPGs
Effective March 1, 2024
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. 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.
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.
These procedures, services, equipment and outpatient pharmaceuticals apply to pediatric members under age 21, and adult members ages 21 and over. Providers should also refer to Limitations and Exclusions, in addition to Sensitive, Confidential or Other Services that do not require PA for Medi-Cal members. If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Inpatient Services1 |
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|---|---|
Hospitalization - Elective |
Elective medical or surgical admissions to non-LA-DHS hospitals2 Includes:
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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 Long-Term Care Intake Line |
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.
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Outpatient Procedures, Services or Equipment |
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|---|---|
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) |
Acupuncture |
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Behavioral health (outpatient services) |
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Bronchial thermoplasty |
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| Dental anesthesia: Intravenous (IV) moderate sedation and deep sedation/general anesthesia | Authorized by Health Net 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:
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| Enteral nutrition products | |
Gender reassignment services (transgender services) |
Authorized by Health Net when provided outside of an LA-DHS facility |
Genetic testing |
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| Leg stent bridge | |
Neuro and spinal cord stimulators, including procedures |
Authorized by Health Net when provided outside of an LA-DHS facility |
Custom orthotics |
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| Palliative care | |
Prosthetics |
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Transplant |
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Transportation |
All non-emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS)
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Medications
- Authorized by Health Net Pharmacy Services when provided outside of LA-DHS facility
OUTPATIENT PHARMACEUTICALS (Submitted Under Medical Benefit) |
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|---|---|
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 |
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Testosterone therapy |
|
- Authorized by Health Net Pharmacy Services
- Coram is Health Net's preferred infusion provider
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) |
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|---|---|
DRUG/THERAPY CLASS |
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| Gene therapy, includes CAR-T therapy | Examples include:
*CAR-T therapy |
GnRH agonists |
Examples include:
Authorization required for non-oncology/non-urology only:
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Hereditary angioedema (HAE) agents |
Examples include:
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| Intravenous (IV) iron agents | Examples include:
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Immune globulin agents |
Examples include:
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Lysosomal storage disorders |
Examples include:
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| Pemetrexed agents | Examples include:
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| Pulmonary arterial hypertension (PAH) agents | Examples include:
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Ranibizumab agents |
Examples include:
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| Tobramycin (inhaled) agents | Examples include:
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Viscosupplementation agents |
Examples include:
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- The following medications require prior authorization from the Health Net 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) | ||||
|---|---|---|---|---|
Actemra® Adakveo® Adcetris® Aduhelm™ Akynzeo® Aliqopa™ Amondys 45™ Amvuttra® Aralast® Arzerra® Asparlas™ Azedra® Bavencio® BCG Intravesical Beleodaq® Benlysta® (ages 0–20 only) Beovu® Besponsa® Blenrep Blincyto® Botox® Brineura™ Briumvi® Cablivi® Ceprotin® (ages 0–20 only) Cinqair® Cortrophin® Cosela™ Crysvita® Cyramza® Danyelza® Darzalex® DDAVP® (ages 0–20 only) Dupixent® Durysta™ Dysport® Elahere™ Elzonris®
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Empaveli™ Empliciti® Enjaymo™ Entyvio™ Epkinly™ Erbitux® Erwinaze® (ages 0–20 only) Evenity® Evkeeza™ Exondys 51™ Eylea® Fasenra™ Faslodex® Folotyn® Fyarro™ Gamifant® Givlaari Glassia™ H.P. Acthar® Gel Halaven® Histrelin acetate Ilumya® Ilaris® Iluvien® Imfinzi® Imjudo® Jelmyto™ Jemperli® Jesduvroq™ Jevtana® Keytruda® Kimmtrak® Krystexxa® Kyprolis® Lemtrada® Leqembi™ Leqvio® Levoleucovorin (Fusilev®, Khapzory™) |
Libtayo® Lumoxiti® Lunsumio™ Lutathera® Macugen® Makena™ Margenza™ Marqibo® Mepsevii™ Monjuvi® Mozobil® Mylotarg™ Myobloc® Myozyme® Nexviazyme® Novantrone® Nplate® Nucala Nulibry™ Nuzyra® Ocrevus™ Oncaspar® Onpattro™ Opdivo® Opdualag™ Orencia® Oxlumo™ Ozurdex® Padcev® Panhematin® Parsabiv® Pepaxto® Perjeta® Phesgo® Polivy™ Poteligeo® Prevymis™ Prolastin® Prolia®
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Provenge® Qalsody™ Radicava™ Radiesse® Reblozyl® Rebyota™ Reclast® Retisert® Revcovi™ Rybrevant™ Rylaze™ Ryplazim® Sandostatin® LAR kit Saphnelo™ Sarclisa® Scenesse® Sculptra® Sensipar® Signifor® LAR Simponi Aria® Sinuva® Skyrizi® Soliris® Somatuline® Depot Sotradecol® Spevigo® Spinraza™ SpravatoTM Stelara® Sunlenca® Sustol® Syfovre™ Synagis® Synribo® Tecentriq® Tecvayli™ Tepezza® Testopel®
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Tezspire® Tivdak™ Tysabri® Tzield™ Ultomiris™ Uplizna® Vabysmo® Valstar® Vectibix® Velcade® (ages 0–20 only) Vidaza® Viltepso® Visudyne® Vyepti™ Vyondys 53® Vyvgart® Vyxeos (ages 0-20 only) Xenpozyme® Xeomin® Xgeva® Xiaflex® Xipere® Xolair® Yervoy® Yutiq™ Zaltrap® Zemaira® Zemdri™ Zepzelca™ Zilretta™ Zinplava™ Zulresso™ Zynlonta® Zynteglo® |
- 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 |
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|---|---|
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 – Remicade® |
Avsola®, Inflectra®, Renflexis® |
Pegfilgrastim agents – Fulphila®, Flynetra®, Neulasta®, Neulasta OnPro®, Nyvepria®, RolvedonTM, Stimufend® |
Udenyca®, Ziextenzo® |
Rituximab agents – Riabni®, Rituxan®, Rituxan Hycela™ |
Ruxience®, Truxima® (no PA required for hematology/oncology indications) |
Trastuzumab agents – Enhertu®, Herceptin®, Herceptin HylectaTM, Herzumz®, Kadcyla®, Ontruzant® |
Kanjinti®, Ogivri®, TrazimeraTM |
Submit a prior authorization request to Health Net
Non-Benefit Service |
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|---|---|
Community Supports
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Refer to CalAIM Resources for Providers |
Below are PA limitations and exclusions for Medi-Cal members.
- 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.
- Non-emergency medical transport (NEMT), ground, for medically necessary outpatient services is available upon request by a provider or member who contacts Modivcare. All NEMT require a PCS.
- 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.
- Emergency room (ER) services after stabilization of an emergency medical condition or when the medical screening exam (MSE) does not demonstrate an emergency medical condition are subject to review by Health Net and may not be paid.
- 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.
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 – those covered services of a sensitive nature that minors do not need parental consent to access or obtain. Such services are those related to sexual assault, including rape; drug or alcohol abuse (for children ages 12 and older); family planning services; pregnancy, including pregnancy termination; HIV counseling and testing; sexually transmitted infection (STI) diagnosis and treatment (for children ages 12 and older); and outpatient mental health services.
- Therapeutic and elective pregnancy termination.
- Family planning, STI diagnosis and treatment, HIV testing and counseling, and sexual assault 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 for more information about locating a CPSP provider.
- Other services not requiring PA:
- Pregnancy care with a participating network obstetrician.
- 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.
- Certified nurse midwife and obstetrical/gynecological (OB/GYN) services from a participating provider do not require PA.
- MOA 638 Indian Health Service facilities
- Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (FDA approved)
- COVID-19 diagnostic and screening testing