20-851 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.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Prior authorization request changes start January 1, 2021
See the table below for prior authorization (PA) requirement changes for Health Net and CalViva Health Medi-Cal fee-for-service providers.
Medications requiring PA effective immediately
The below medications require PA immediately 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 current PA requirements online
Follow the steps below to find out if PA is needed for any procedures, services or equipment:
1 Go to provider.healthnet.com.
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.
Additional information
Providers are encouraged to access the provider portal online at provider.healthnet.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.
Medi-Cal fee-for-service PA Changes
Below are PA requirement changes for Medi-Cal fee-for-service providers. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.
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 |
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, refer to the DOFR crosswalk located in the Provider Library. Select Provider Manual > Benefits > Injectable > Self-Injectable Medications > Health Net Injectable Medications HCPCS/DOFR Crosswalk (PDF). | Existing | Existing |
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 |