20-853 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.
Prior authorization request changes start January 1, 2021
Health Net is implementing changes to the Cal MediConnect Plan (Medicare-Medicaid Plan) prior authorization (PA) requirements as outlined in the table below.
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 authorization requirements online
Follow the steps below to find out if PA is needed for any procedures, services or equipment:View authorization requirements online
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 Health Net’s provider portal 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 the Health Net Provider Services Center by email within 60 days, by telephone or through the Health Net provider website as listed in the right-hand column.
Cal MediConnect PA Changes
Below are PA requirement changes for Cal MediConnect medical benefits plan.
Requirement | Comments | |||
|---|---|---|---|---|
Biosimilars | Biosimilars are required to be used in lieu of branded drugs. | |||
| Listed under Outpatient Pharmaceuticals (Submitted under Medical Plan). Leuprolide Depot examples include Eligard®, Lupron Depot®. |
Requirement | Comments |
|---|---|
Durable medical equipment (DME) | Prior authorization is required for CPAP and BiPap devices, but will discontinue review of related supplies. |
Occupational and speech therapy | Requires prior authorization after 12 combined outpatient therapy visits (occupational, speech and physical). Visits 1-12 no longer require authorization. |
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 Provider Library. Select Provider Manual > Benefits > Injectable > Self-Injectable Medications > Health Net Injectable Medications HCPCS/DOFR Crosswalk (PDF). |
Bendeka® |