20-439 New Prior Authorization Requirements
Date: 06/08/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Request prior authorizations for medications listed in this update
Please review the medications in this update to find out when you need to request prior authorization (PA).
Medications requiring PA immediately
The below medications require PA immediately per new injectable medication HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) on April 1, 2020:
| Medication | Line of business |
Adakveo®, Givlaari® | Medi-Cal fee-for-service (FFS), commercial, Medicare HMO and Centene Corporation Employee PPO plans |
Quzyttir™ | Medicare HMO only |
New PA requirements starting August 11, 2020
You will need to request PA for the medications listed below (excludes Medicare HMO):
Blincyto® | Ozurdex® | Synribo® | Vyondys 53® |
Erbitux® | Panhematin® | Triptodur® | Yutiq™ |
Faslodex® | Retisert® | Vectibix® | Zaltrap® |
Mozobil® | Revcovi™ | Vidaza® |
|
The above medications apply to Health Net* Medi-Cal FFS, commercial and Centene Corporation Employee PPO plans. They are listed in the PA list under Outpatient Pharmaceuticals (Submitted under Medical Plan).
View PA requirements online
You can access current PA requirements and directions to submit requests using the directions below.
If you are servicing a member enrolled in… | Access prior authorization requirements with these steps |
| 1 Go to provider.healthnet.com 2 Pre-log in, select Working with 3 Post-log in, select Working with
|
Individual MA HMO and Special Needs Plan (SNP) | 1 Go to ca.healthnetadvantage.com 2 Select I’m A Provider > Medicare 3 Enter the service code 4 If the code requires prior authorization, log in to provider.healthnetcalifornia.com to submit an authorization request |
| 1 Go to ifp.healthnetcalifornia.com 2 Select For Providers 3 Enter the service code 4 If the code requires prior authorization, log in to provider.healthnetcalifornia.com to submit an authorization request |
Additional information
If you have questions regarding the information above, contact the applicable Health Net Provider Services Center at:
| Line of Business | Telephone Number | Provider Portal | Email Address |
EnhancedCare PPO (IFP) | 1-844-463-8188 | provider.healthnetcalifornia.com | provider_services@healthnet.com |
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider.healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider.healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider.healthnetcalifornia.com | |
Medicare (individual) | 1-800-929-9224 | provider.healthnetcalifornia.com | |
Medicare (employer group) | 1-800-929-9224 | provider.healthnet.com | |
Medi-Cal | 1-800-675-6110 | provider.healthnet.com | N/A |