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20-092 Prior Authorization Requirements

Date: 01/24/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Additions and changes, effective April 1, 2020

See below for prior authorization (PA) requirement changes for Medi-Cal fee-for-service (FFS) providers. “New” indicates new requirement and “Existing” indicates current requirement.



Adult members ages 21 and over

Pediatric members under age 21

Continuous glucose monitoring

Listed under Durable Medical Equipment (DME)

New benefit

Existing benefit under CCS.1 All DME requires prior authorization.

H. pylori (Helicobacter pylori), antibody testing

Listed under Outpatient Procedures



Listed under Outpatient Procedures

Removed HLA typing

Added Transplants must be performed through Health Net’s designated transplantation specialty network

Aliqopa, azedra®, Beouvu®, Besponsa®, Folotyn®, Kanuma®, Lutathera®, Polivy

Listed under Outpatient Pharmaceuticals


1CCS – California Children’s Services

View authorization requirements online

Follow the steps below to find out if prior authorization is needed for any procedures, services or equipment:

1     Go to

2     Before logging in, select Working with Health Net > Policies for Non-Contracting Providers > Additional Resources > Services Requiring Prior Authorization.

3     After logging in, select Working with Health Net > Contractual > Services Requiring Prior Authorization.

If you have questions regarding the information contained in this update, contact
CalViva Health at 1-888-893-1569.

Last Updated: 04/01/2020