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Prior Authorization Requirements

California
Medi-Cal

Effective August 1, 2024

The services, procedures, equipment and outpatient pharmaceuticals below apply to Health Net, CalViva Health and Community Health Plan of Imperial Valley Medi-Cal fee-for-service (FFS) members in the following counties:

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.

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.

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 are available on the Medi-Cal member page under Medi-Cal Member Handbooks.

Eligibility rules and limitations 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 – all services, procedure, equipment, or outpatient pharmaceuticals are subject to benefit plan coverage limitations.

Submit a PA request

PA timelines

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.

PA limitations and exclusions, in addition to sensitive, confidential or other services that do not require PA for Medi-Cal members, are provided below.

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:

  • acute care hospital
  • acute or sub-acute rehabilitation facility

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

Long-term care nursing facility admissions

Contact the Health Net Long-Term Care Intake Line

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

To receive urgent status for routine services requiring authorization related to a clinical trial, include the Attestation form in your request or indicate “Routine Care Cost Services Associated with the Clinical Trial”

X

X

Cochlear implants

X

X

Community-Based Adult Services (CBAS)

  • PA is required for greater than 5 visits per week
  • CBAS services with 1-5 visits per week require notification only
  • Fax authorization and notifications to: 833-581-5908 (Face-to-face, authorization and notification requests)

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 Evolent Specialty Services, Inc. (Evolent)

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

Durable medical equipment (DME)

Adult members including, but not limited to:

  • BiLevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP)
  • Bone growth stimulator
  • Continuous glucose monitoring
  • Custom-made items
  • Hospital beds and mattresses
  • Items with a total Medi-Cal purchase price greater than $1,500
  • Oxygen
  • Power wheelchairs
  • Scooters
  • Ventilators

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

Implantable pain pumps

Authorized by TurningPoint Healthcare Solutions , LLC

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

Medications requiring PA

Contact Health Net Pharmacy Services

X

Neuro and spinal cord stimulators, including procedures

X

X

Orthognathic procedures (includes TMJ treatment)

X

X

Out-of-network providers and services

  • Services rendered by out-of-network providers require PA
  • Excludes emergency services and self-referral services allowed under the Medi-Cal plan for family planning, pregnancy termination, HIV counseling and testing, immunizations at the local health department, and sexually transmitted infections (STIs)

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

Proprietary laboratory analyses

Includes the following CPT®codes: 0457U, 0459U, 0462U, 0468U, 0472U

X

X

Prosthetics

X

Quantitative drug screening

X

X

Radiation therapy – pediatric members

X

Radiation therapy – adult members

Limited to:

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

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)
  • Dermatology, such as chemical exfoliation and electrolysis, dermabrasions and chemical peels, laser treatment or skin injections and implants
  • 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
  • Muscle flap
  • Nasal surgery, such as rhinoplasty or septoplasty
  • Otoplasty
  • Penile implant
  • Treatment of varicose veins

X

X

Rehabilitation services

Physical, occupational and speech therapy require authorization after 12 combined visits. Includes home setting

X

Sleep studies

  • Facility based sleep testing

X

X

Spinal surgery – includes, but is not limited to, laminotomy, fusion, diskectomy, vertebroplasty, nucleoplasty, stabilization, and X-Stop

X

X

Transplant

  • Fax requests to the Transplant Team
  • Transplant evaluations and procedures, including, but not limited to, evaluation, transplant consult visits, donor search, and transplant procedure

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:

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

Outpatient Pharmaceuticals (Submitted Under Medical Benefit)

Medications

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

  • Self-injectable medications are the responsibility of the Medi-Cal Rx Program effective 1/2/22
  • Refer to the Contract Drug List (CDL) on the DHCS website for the Medi-Cal Rx list of covered drugs and services. PA may be required, and providers may use Cover My Meds to submit a PA request or complete a Prior Authorization Form and fax it to 800-859-4325
  • PA required from Health Net for self-injectable medications administered in a physician's office

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, RoctavianTM, Skysona®, TecartusTM*, YescartaTM*, Zynteglo®, Zolgensma®

    *CAR-T therapy

GnRH agonists

Examples include:

  • Camcevi®, Eligard®, Fensolvi®, Lupron Depot®, Lupron Depot-Ped®, Supprelin® LA, 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:

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

Immune globulin agents

Examples include:

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

Lysosomal storage disorders

Examples include:

  • Aldurazyme®, Brineura™, Cerezyme®, Elaprase®, Elelyso®, Elfabrio®, Fabrazyme®, Kanuma®, Lamzede®, Lumizyme®, Mepsevii™, Naglazyme®, Nexviazyme®, Pombiliti™, Vimizim®, Vpriv®, Xenpozyme®
Pemetrexed agents

Examples include:

  • Alimta® (no PA for generic), Pemfexy TM, Pemrydi RTU® and other generic
Pulmonary arterial hypertension (PAH) agents

Examples include:

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

Ranibizumab agents

Examples include:

  • ByoovizTM, CimerliTM, Lucentis®, Susvimo™
Tobramycin (inhaled) agents

Examples include:

  • Bethkis®, Katabis®, TOBI® (ages 0-20 only)

Viscosupplementation agents

Examples include:

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

Abrilada™

Actemra®

Adakveo®

Adcetris®

Adzynma™

Akynzeo®

Aliqopa™

Amondys 45™

Amvuttra®

Aphexda®

Aralast®

Arzerra®

Asparlas™

Azedra®

Bavencio®

BCG Intravesical

Beleodaq®

Benlysta®

Beovu®

Besponsa®

Blincyto®

Botox®

Briumvi®

Cablivi®

Casgevy™

Ceprotin® (ages 0–20 only)

Cimzia®

Cinqair®

Columvi™

Cortrophin®

Cosela™

Cosentyx®

Crysvita®

Cyramza®

Danyelza®

Darzalex®

Daxxify®

DDAVP® injectable (ages 0–20 only)

Dupixent®

Durysta™

Dysport®

Elahere™

Elrexfio™

Elzonris®

Empaveli™

Empliciti®

Enjaymo™

Entyvio™

Epkinly™

Erbitux®

Erwinaze® (ages 0–20 only)

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®

Izervay™

Jelmyto™

Jemperli®

Jesduvroq™

Jevtana®

Keytruda®

Kimmtrak®

Krystexxa®

Kyprolis®

Lemtrada®

Leqembi™

Leqvio®

Levoleucovorin (Fusilev®, Khapzory™)

Libtayo®

Loqtorzi™

Lumoxiti®

Lunsumio™

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™

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™

SpravatoTM

Stelara®

Sustol®

Syfovre™

Synagis®

Synribo®

Talvey™

Tecentriq®

Tecvayli™

Tepezza®

Testopel®

Tezspire®

Tivdak™

Tofidence™

Trodelvy®

Tyruko®

Tysabri®

Tzield™

Ultomiris™

Unituxin®

Uplizna®

Vabysmo®

Valstar®

Vectibix®

Velcade® (ages 0–20 only)

Veopoz™

Vidaza®

Viltepso®

Visudyne®

Vyepti™

Vyjuvek®

Vyondys 53®

Vyvgart®

Vyvgart Hytrulo

Vyxeos (ages 0-20 only)

Wezlana™

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 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 (PA not required for Retacrit when administered/provided under the medical benefit)

Filgrastim agents – Granix®, Neupogen®, Releuko®

  • Nivestym®
  • Zarxio® (PA not required for Zarxio when administered/provided under the medical benefit)

Infliximab agents – Remicade®

Avsola®, Inflectra®, Renflexis®

Pegfilgrastim agents – Fulphila®, Fylnetra®, Neulasta®, Neulasta OnPro®, Nyvepria®, RolvedonTM, Ryzneuta™, Stimufend®

Udenyca®, Udenyca Onbody,  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

  • Asthma remediation
  • Community transition services/nursing facility transition to a home
  • Day habilitation
  • Environmental accessibility adaptations (home modifications)
  • Housing deposits
  • Housing tenancy and sustaining services
  • Housing transition navigation services
  • Meals/medically tailored meals
  • Nursing facility transition/diversion to assisted living facilities
  • Personal care and homemaker services
  • Recuperative care (medical respite)
  • Respite services
  • Short-term post-hospitalization housing

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

prior authorization exceptions

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

CCS services must be provided by CCS-paneled providers and at CCS-approved facilities.

X

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.

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:

  • 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

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:

  • 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 his or her county
  • Certified nurse midwife and obstetrical/gynecological (OB/GYN) services from a participating provider
  • MOA 638 Indian Health Service facilities
  • Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (must be FDA-approved)

X

X
Last Updated: 10/08/2024