HealthNet.com

20-850 Learn What Services Will Now Require a Prior Authorization Request

Date: 10/27/20

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.

Prior authorization request changes start January 1, 2021

Please review the prior authorization (PA) requirement changes listed below.

Medications requiring PA effective immediately

The below medications require PA immediately for all products per new injectable medication HCPCS codes issued by the Centers for Medicare & Medicaid Services on October 1, 2020:

Durysta^™
Istodax^®
Jelmyto^™
Monoferric^®
Pemfexy^™
Sarclisa^®
Tepezza^®
Trodelvy^™
Vyepti^™
Zulresso^™

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
Employer group HMO, PPO, EPO Point of Service (POS) Medi-Cal	1 Go to the Health Net provider portal. 2 Pre-log in, select Working with Health Net > Policies for Non-Contracting Providers > Additional Resources > Services Requiring Prior Authorization. 3 Post-log in, select Working with Health Net > Contractual > Services Requiring Prior Authorization.
IFP CommunityCare HMO IFP PureCare HSP PPO Individual and Family IFP EnhancedCare PPO IFP PureCare One EPO	1 Go to the IFP provider portal, select For Providers > Working with Health Net. 2 Under Additional Resources, select Services Requiring Prior Authorization. 3 Select the product under Online Prior Authorization Validation Tools. 4 If the code requires prior authorization, log in to the Health Net provider portal to submit an authorization request.

If you are servicing a member enrolled in…

Access prior authorization requirements with these steps

Employer group HMO, PPO, EPO
Point of Service (POS)
Medi-Cal

1 Go to the Health Net provider portal.

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

3 Post-log in, select Working with
Health Net > Contractual > Services Requiring Prior Authorization.

IFP CommunityCare HMO
IFP PureCare HSP
PPO Individual and Family
IFP EnhancedCare PPO
IFP PureCare One EPO

1 Go to the IFP provider portal, select For Providers > Working with Health Net.

2 Under Additional Resources, select Services Requiring Prior Authorization.

3 Select the product under Online Prior Authorization Validation Tools.

4 If the code requires prior authorization, log in to the Health Net provider portal to submit an authorization request.

If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days as listed below.

Medi-Cal fee-for-service

The below PA requirement changes are for Health Net’s Medi-Cal fee-for-service providers. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.

Additions, effective January 1, 2021
Requirement	Comments	Adult members ages 21 and over	Pediatric members under age 21
Biosimilars	Biosimilars are required to be used in lieu of branded drugs.	New	New
Remodulin^®, Ruconest^®	Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan).	New	New

Changes, effective January 1, 2021
Requirement	Comments	Adult members ages 21 and over	Pediatric members under age 21
Rehabilitation services Includes physical, occupational and speech therapy	Requires prior authorization after 12 combined outpatient therapy visits. Visits 1-12 no longer require authorization.	N/A	Existing
Durable medical equipment (DME)	Prior authorization is required for CPAP and BiPap devices, but will discontinue review of related supplies.	Existing	Existing
Leuprolide Depot (non-oncology/non-urology only)	Changed from “Eligard^®^” to “Leuprolide Depot.^” Examples include Eligard^®, Lupron Depot^®. Now excludes urology providers.	Existing	Existing
Self-injectables	Removed select medications (Aranesp^®, Benlysta^®,Cosentyx^®, Granix^®, Mircera^®, Takhzyro^™) from the list, but still require PA under self-injectables. For a list of self-injectables, go to the Provider Library at providerlibrary.healthnetcalifornia.com. Select Provider Manual > Benefits > Injectable > Self-Injectable Medications > Health Net Injectable Medications HCPCS/DOFR Crosswalk (PDF).	Existing	Existing

Deletions, effective January 1, 2021
Requirement	Comments	Adult members ages 21 and over	Pediatric members under age 21
Bendeka^®, Reclast^®, Zemplar^®, Zometa^®	Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan).	Existing	Existing

Commercial

Select lines of business have been abbreviated as follows: CommunityCare HMO is CC; CommunityCare HMO PPGs is CC PPGs; POS Tiers 1, 2 and 3 are POS T1, POS T2 and POS T3; out-of-state PPO is OOS PPO. Application of authorization requirement changes to EPO, PPO, OOS PPO, and Flex Net are based on group renewal date. Contact Health Net to confirm whether specific services require PA for group plans. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.

Additions, effective January 1, 2021
Line of business
Requirement	Comments	HMO, CC, HSP, POS T1	CC PPGs	POS T2, POS T3	EPO, PPO, OOS PPO, Flex Net
Biosimilars	Biosimilars are required to be used in lieu of branded drugs.	New	New	New	New
Continuous glucose monitoring	This is added under the durable medical equipment (DME) category.	New	New	New	N/A
Leuprolide Depot (non-oncology/non-urology only) Ruconest^® Yervoy^®	Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan). Leuprolide Depot examples include Eligard^®, Lupron Depot^®.	New	New	New	New

Changes, effective January 1, 2021
Line of business
Requirement	Comments	HMO, CC, HSP, POS T1	CC PPGs	POS T2, POS T3	EPO, PPO, OOS PPO, Flex Net
Durable medical equipment (DME)	Prior authorization is required for CPAP and BiPap devices, but will discontinue review of related supplies.	Existing	Existing	Existing	Existing
Occupational and speech therapy	Requires prior authorization after 12 combined outpatient therapy visits (occupational, speech and physical). Visits 1-12 no longer require authorization.	Existing	Existing	Existing	Existing
Self-injectables	Removed select medications (Aranesp^®, Benlysta^®,Cosentyx^®, Mircera^®, Takhzyro^™) from the list, but still require PA under self-injectables. For a list of self-injectables, refer to the DOFR crosswalk located in the Health Net Provider Library. Select Provider Manual > Benefits > Injectable > Self-Injectable Medications > Health Net Injectable Medications HCPCS/DOFR Crosswalk (PDF).	Existing	Existing	Existing	Existing

Deletions, effective January 1, 2021
Line of business
Requirement	Comments	HMO, CC, HSP, POS T1	CC PPGs	POS T2, POS T3	EPO, PPO, OOS PPO, Flex Net
Bendeka^®		Existing	Existing	Existing	Existing

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	provider_services@healthnet.com
Health Net Employer Group HMO, POS, HSP, PPO, & EPO	1-800-641-7761	provider.healthnet.com	provider_services@healthnet.com
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO)	1-888-926-2164	provider.healthnetcalifornia.com	provider_services@healthnet.com
Medi-Cal	1-800-675-6110	provider.healthnet.com	N/A

Last Updated: 10/29/2020