Prior Authorization Requirements
California
Medi-Cal
Effective March 1, 2024
The services, procedures, equipment and outpatient pharmaceuticals below apply to Health Net and CalViva Health Medi-Cal fee-for-service (FFS) members in the following counties:
- Amador, Calaveras, Inyo, Los Angeles (including Molina providers), Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne
- Fresno, Kings and Madera (CalViva Health) – providers servicing CalViva Health members can also access prior authorization requirements here (PDF)
- Imperial (Community Health Plan of Imperial Valley (CHPIV)) – providers servicing CHPIV members can also access prior authorization requirements here (PDF)
These are subject to prior authorization (PA) requirements (unless noted as "notification" required only) if an “X” is included under the applicable age group. 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. Providers are responsible for verifying member eligibility through the 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.
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 are available on the Medi-Cal member page under Medi-Cal Member Handbooks. PA limitations and exclusions, in addition to sensitive, confidential or other services that do not require PA for Medi-Cal members, are provided below.
Submit a prior authorization request to Health Net unless stated differently in requirements listed below. Requests should be submitted to Health Net via fax. The Health Net Request for Prior Authorization form 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.
If members have questions regarding the PA list or requirements, refer to the member services number listed on their identification card.
Inpatient Services
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Inpatient Services1
| Adult Members Ages 21 and over | Pediatric Members Under Age 21 |
|---|---|---|
Skilled nursing facilities All elective admissions | X | X |
All elective medical and surgical inpatient hospitalizations Includes, but is not limited to:
Musculoskeletal procedures for adult members authorized by TurningPoint Healthcare Solutions, LLC | X | X |
All emergency hospitalizations within 24 hours of hospital admission
| X | X |
All hospitalizations to a nonparticipating hospital once emergency stabilization is complete | X | X |
1Procedures performed during acute inpatient hospitalization are included under the inpatient PA (excluding experimental and investigational procedures). Procedures in emergency situations do not require PA.
Outpatient Services
Submit a prior authorization request to Health Net unless stated differently in requirements listed below.
Outpatient Services | Adult Members Ages 21 and over | Pediatric Members Under Age 21 |
|---|---|---|
Ablative techniques for treating Barrett’s esophagus and for treatment of primary and metastatic liver malignancies | X | X |
Acupuncture
| X | X |
Bariatric surgeries, such as laparoscopic gastric banding | X | X |
Behavioral health (outpatient services)
| X | X |
Bronchial thermoplasty | X | X |
Capsule endoscopy | X | X |
Cardiac procedures | X | |
Clinical trials | X | X |
Cochlear implants | X | X |
Community-Based Adult Services (CBAS)
| X | X |
Custom orthotics | X | X |
Dental anesthesia: Intravenous (IV) moderate sedation and deep sedation/general anesthesia | X | X |
Developmental screening PA required for ages 6–20 | X | |
Diagnostic procedures Authorized by National Imaging Associates, Inc. (NIA) Advanced imaging:
Cardiac imaging:
| X | X |
Durable medical equipment (DME) Adult members including, but not limited to:
All DME for pediatric members requires PA | X | X |
Enteral nutrition products | X | X |
Experimental/investigational services and new technologies Includes, but is not limited to, those listed in the Investigational Procedures List (PDF) | X | X |
Gender reassignment services (Transgender services) | X | X |
Genetic testing | X | X |
H. pylori (Helicobacter pylori) antibody testing | X | X |
Intensive cardiac rehabilitation | X | X |
Joint surgeries – includes ankle, hip, knee and shoulder
| X | X |
Leg stent bridge | X | X |
Lung volume reduction | X | X |
Maze procedures | X | X |
Neuro and spinal cord stimulators, including procedures
| X | X |
Orthognathic procedures (includes TMJ treatment) | X | X |
Out-of-network providers and services
| X | X |
Outpatient infusion therapy Includes, but is not limited to, blood transfusions and chemotherapy | X | |
Outpatient elective surgery | X | |
Palliative care | X | X |
Private duty nursing services Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services | X | |
Prosthetics | X | |
Quantitative drug screening
| X | X |
Radiation therapy – pediatric members
| X | |
Radiation therapy – adult members Limited to:
| X | |
Reconstructive and cosmetic surgery, services and supplies Surgery, services and supplies, including, but not limited to:
| X | X |
Rehabilitation services Physical, occupational and speech therapy require authorization after 12 combined visits. Includes home setting | X | |
Sleep studies
| X | X |
Spinal surgery – includes, but is not limited to, laminotomy, fusion, diskectomy, vertebroplasty, nucleoplasty, stabilization, and X-Stop
| X | X |
Transplant
| X | X |
Transportation
| X | X |
Trigger point and sacroiliac (SI) joint injections | X | X |
Uvulopalatopharyngoplasty (UPPP) and laser-assisted UPPP | X | X |
Ventriculectomy, cardiomyoplasty | X | X |
Vestibuloplasty Surgical procedure | X | X |
Wound care Including but not limited to:
| X | X |
Outpatient Pharmaceuticals (Submitted Under Medical Benefit)
Medications
- Authorized by Health Net 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 Health Net Pharmacy Services to confirm |
Self-injectables |
|
Testosterone therapy | Authorized by Health Net Pharmacy Services |
- 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:
|
Tobramycin (inhaled) agents | Examples include:
|
Viscosupplementation agents | Examples include:
|
- The following medications require prior authorization from the Health Net Pharmacy Services
Outpatient Pharmaceuticals (Submitted Under Medical Benefit) | ||||
|---|---|---|---|---|
Actemra® Adakveo® Adcetris® Aduhelm™ Akynzeo® Aliqopa™ Amondys 45™ Amvuttra® Aralast® Asparlas™ Azedra® Bavencio® BCG Intravesical Beleodaq® Benlysta® (ages 0–20 only) Beovu® Besponsa® Blenrep Blincyto® Botox® Brineura™ Briumvi® Cablivi® CAR-T Ceprotin® (ages 0–20 only) Cinqair® Cosela™ Crysvita® Cyramza® Danyelza® Darzalex® decitabine (Sun Pharma) DDAVP® injectable (ages 0–20 only) Dupixent® Durysta™ Dysport® Elahere™ Elzonris® Empaveli™ Empliciti® | Enjaymo™ Entyvio™ 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 Ilaris® Ilumya® Iluvien® Imfinzi® Imjudo® Jelmyto™ Jemperli® 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® Nplate® Nucala Nulibry™ Nuzyra® Ocrevus™ Oncaspar® Onpattro™ Opdivo® Opdualag™ Orencia® Oxlumo™ Ozurdex® Padcev® Panhematin® Parsabiv® Pepaxto® Perjeta® Phesgo® Polivy™ Poteligeo® Prevymis™ Prolastin® | Prolia® Provenge® Radicava™ Radiesse® Reblozyl® Rebyota™ Retisert® Revcovi™ Rybrevant™ Rylaze™ Ryplazim® Sandostatin® LAR kit Saphnelo™ Sarclisa® Scenesse® Sculptra® Sensipar® Simponi Aria® Sinuva® Skyrizi® Soliris® Somatuline® Depot Sotradecol® Spevigo® Spinraza™ SpravatoTM Stelara® Sunlenca® Sustol® Syfovre™ Synagis® Synribo® Tecentriq® Tecvayli™ Tepezza® Testopel® Tezspire® Tivdak™ | Tysabri® Tzield™ Ultomiris™ Uplizna® Vabysmo® 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 | |
|---|---|
NON-PREFERRED BIOSIMILARS | PREFERRED BIOSIMILARS |
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®, Fylnetra®, Neulasta®, Neulasta OnPro®, Nyvepria®, RolvedonTM, Stimufend® | Udenyca®, Ziextenzo® |
Rituximab agents – Riabni®, Rituxan®, Rituxan HycelaTM | Ruxience®, Truxima® (no PA required for hematology/oncology indications) |
Trastuzumab agents – Enhertu®, Herceptin®, Herceptin HylectaTM, Herzuma®, Kadcyla®, Ontruzant® | Kanjinti®, Ogivri®, TrazimeraTM |
Non-Benefit Services Requiring Authorization
Non-Benefit Services | Adult Members Ages 21 and over | Pediatric Members Under Age 21 |
|---|---|---|
Community Supports
Refer to CalAIM Resources for Providers | X | X |
Limitations and exclusions, and Prior Authorization Exceptions
Listed below are PA limitations and exclusions, in addition to sensitive, confidential and other services that do not require PA for adult or pediatric Medi-Cal members.
Limitations and exclusions, and | Adult Members Ages 21 and over | Pediatric Members Under Age 21 |
|---|---|---|
Authorization for carve-out services not covered by Health Net or CalViva Health, such as CCS-eligible conditions, requires PA from the local CCS office. | X | |
Routine laboratory and radiology services must be performed at a Health Net or CalViva Health participating facility. | X | X |
Non-emergency medical transport (NEMT), ground, for medically necessary outpatient services and non-medical transportation (NMT) is available upon request by a provider or member who contacts Modivcare. All NEMT require a PCS form. | X | X |
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 Medi-Cal Member Services. | X | X |
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. | X | X |
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. | X | X |
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). | X | |
Referral or PA is not required for the following sensitive services, and the services may be obtained from any qualified in-network or out-of-network provider:
| X | X |
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. | X | X |
Other services not requiring PA:
| X | X |