20-960 Learn What Services Will Now Require a Prior Authorization Request

Employer group Medicare Advantage (MA) HMO

1. Go to the provider website
2. Pre-log in, select Working with Health Net, under Additional Resources, select Services Requiring Prior Authorization
3. Post-log in, select Working with Health Net > Contractual > Services Requiring Prior Authorization

Individual MA HMO and Special Needs Plan (SNP)

1. Go to the Health Net Medicare Advantage website, 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 provider website to submit an authorization request

Biosimilars

Chondrocyte implants

Hysterectomy

Sacral nerve neuromodulation

Durable medical equipment (DME)

Added:

• Lymphedema pumps and supplies
• Vagus nerve stimulator
• Select DME codes will require authorization. To confirm whether a specific code requires authorization, go to the Health Net Medicare Advantage website > For Providers > Working with Health Net > Services Requiring Prior Authorization > select Medicare Plans under Online Prior Authorization Validation Tools and follow the prompts. This tool is updated upon the effective date of the changes.

Outpatient therapies: physical, occupational and speech

Evaluation and up to 12 visits no longer require authorization.

Visits exceeding 12 require authorization.

Part B Medications

The medications are now listed with corresponding codes for easier lookup.

Part B medications requiring authorization are listed under Outpatient Pharmaceuticals (Submitted under Medical Plan) in the authorization list, effective January 1, 2021.

To see a comprehensive list of part B medications:

1. Go to the Provider Library
2. Select Medicare Advantage
3. Select Updates and Letters > search for provider update 20-960 under 2020 Updates and Letter

You may request a print copy of update 20-960 by contacting the
Health Net Provider Communications Department by email.

Sleep studies

1. Employer group Medicare Advantage (MA) HMO

1. Go to the provider website
2. Pre-log in, select Working with Health Net, under Additional Resources, select Services Requiring Prior Authorization
3. Post-log in, select Working with Health Net > Contractual > Services Requiring Prior Authorization

Individual MA HMO and Special Needs Plan (SNP)

1. Go to the Health Net Medicare Advantage website, 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 provider website to submit an authorization request

Biosimilars

Chondrocyte implants

Hysterectomy

Sacral nerve neuromodulation

Durable medical equipment (DME)

Added:

• Lymphedema pumps and supplies
• Vagus nerve stimulator
• Select DME codes will require authorization. To confirm whether a specific code requires authorization, go to the Health Net Medicare Advantage website > For Providers > Working with Health Net > Services Requiring Prior Authorization > select Medicare Plans under Online Prior Authorization Validation Tools and follow the prompts. This tool is updated upon the effective date of the changes.

Outpatient therapies: physical, occupational and speech

Evaluation and up to 12 visits no longer require authorization.

Visits exceeding 12 require authorization.

Part B Medications

The medications are now listed with corresponding codes for easier lookup.

Part B medications requiring authorization are listed under Outpatient Pharmaceuticals (Submitted under Medical Plan) in the authorization list, effective January 1, 2021.

To see a comprehensive list of part B medications:

1. Go to the Provider Library
2. Select Medicare Advantage
3. Select Updates and Letters > search for provider update 20-960 under 2020 Updates and Letter

You may request a print copy of update 20-960 by contacting the
Health Net Provider Communications Department by email.

Sleep studies

892

Special processed drugs – FDA-approved gene therapy

A9513

Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m mebrofenin, per mCi

C9062

Injection, daratumumab 10 mg and hyaluronidase-fihj

C9064

Mitomycin pyelocalyceal instillation, 1 mg

C9065

Injection, romidepsin, non-lypohilized (e.g. liquid), 1 mg

C9066

Injection, sacituzumab govitecan-hziy, 10 mg

C9122

Mometasone furoate sinus implant, 10 mcg (Sinuva^®)

C9399

Unclassified drugs or biologicals

J0129      

Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not for use when drug is self-administered)

J0135

Injection, adalimumab, 20 mg

J0178      

Injection, aflibercept, 1 mg

J0179

Injection, brolucizumab-dbll, 1 mg

J0180

Injection, agalsidase beta, 1 mg

J0202

Injection, alemtuzumab, 1 mg

J0220

Injection, alglucosidase alfa, 10 mg, not otherwise specified

J0221

Injection, alglucosidase alfa, (Lumizyme^®), 10 mg

J0222

Injection, patisiran, 0.1 mg

J0223

Injection, givosiran, 0.5 mg

J0256

Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg

J0257

Injection, alpha 1 proteinase inhibitor (human), (Glassia^®), 10 mg

J0364

Injection, apomorphine HCl, 1 mg

J0490

Injection, belimumab, 10 mg

J0517

Injection, benralizumab, 1 mg

J0567

Injection, cerliponase alfa, 1 mg

J0570

Buprenorphine implant, 74.2 mg

J0584      

Injection, burosumab-twza, 1 mg

J0585      

Injection, onabotulinumtoxinA, 1 unit

J0586

Injection, abobotulinumtoxinA, 5 units

J0587

Injection, rimabotulinumtoxinB, 100 units

J0588

Injection, incobotulinumtoxinA, 1 unit

J0591

Injection, deoxycholic acid, 1 mg

J0593

Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician; not for use when drug is self-administered)

J0598

Injection, C1 esterase inhibitor (human), Cinryze^®, 10 units

J0599

Injection, C1 esterase inhibitor (human), (Haegarda^®), 10 units

J0604      

Cinacalcet, oral, 1 mg, (for ESRD on dialysis)

J0606

Injection, etelcalcetide, 0.1 mg

J0630

Injection, calcitonin salmon, up to 400 units

J0638

Injection, canakinumab, 1 mg

J0641

Injection, levoleucovorin, not otherwise specified, 0.5 mg

J0642

Injection, levoleucovorin (Khapzory^™), 0.5 mg

J0717      

Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not for use when drug is self-administered)

J0775

Injection, collagenase, clostridium histolyticum, 0.01 mg

J0791

Injection, crizanlizumab-tmca, 5 mg

J0800      

Injection, corticotropin, up to 40 units

J0881

Injection, darbepoetin alfa, 1 mcg (non-ESRD use)

J0885

Injection, epoetin alfa, (for non-ESRD use), 1000 units

J0888

Injection, epoetin beta, 1 mcg, (for non-ESRD use)

J0894

Injection, decitabine, 1 mg

J0896

Injection, luspatercept-aamt, 0.25 mg

J0897      

Injection, denosumab, 1 mg

J1190

Injection, dexrazoxane HCl, per 250 mg

J1300      

Injection, eculizumab, 10 mg

J1301

Injection, edaravone, 1 mg

J1303

Injection, ravulizumab-cwvz, 10 mg

J1324

Injection, enfuvirtide, 1 mg

J1428      

Injection, eteplirsen, 10 mg

J1429

Injection, golodirsen, 10 mg

J1437

Injection, ferric derisomaltose, 10 mg

J1438

Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician; not for use when drug is self-administered)

J1439

Injection, ferric carboxymaltose, 1 mg

J1442

Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcg

J1443

Injection, ferric pyrophosphate citrate solution, 0.1 mg of iron

J1447

Injection, tbo-filgrastim, 1 mcg

J1458

Injection, galsulfase, 1 mg

J1459      

Injection, immune globulin (Privigen^®), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1555      

Injection, immune globulin (Cuvitru^®), 100 mg

J1556      

Injection, immune globulin (Bivigam^®), 500 mg

J1557      

Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1558

Injection, immune globulin (Xembify^®), 100 mg

J1559      

Injection, immune globulin (Hizentra^®), 100 mg

J1561      

Injection, immune globulin, (Gamunex^®/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid),
500 mg

J1562

Injection, immune globulin (Vivaglobin^®), 100 mg

J1566      

Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified,
500 mg

J1568      

Injection, immune globulin, (Octagam^®), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1569      

Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg

J1572      

Injection, immune globulin, (Flebogamma^®/Flebogamma DIF), intravenous, nonlyophilized (e.g., liquid), 500 mg

J1575      

Injection, immune globulin/hyaluronidase, 100 mg immuneglobulin

J1599      

Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified,
500 mg

J1602      

Injection, golimumab, 1 mg, for intravenous use

J1628

Injection, guselkumab, 1 mg

J1632

Injection, brexanolone, 1 mg

J1640

Injection, hemin, 1 mg

J1645

Injection, dalteparin sodium, per 2500 IU

J1675

Injection, histrelin acetate, 10 mcg

J1743

Injection, idursulfase, 1 mg

J1744

Injection, icatibant, 1 mg

J1745      

Injection, infliximab, excludes biosimilar, 10 mg

J1746

Injection, ibalizumab-uiyk, 10 mg

J1786

Injection, imiglucerase, 10 units

J1817

Insulin for administration through DME (i.e., insulin pump) per 50 units

J1930      

Injection, lanreotide, 1 mg

J1931

Injection, laronidase, 0.1 mg

J2170

Injection, mecasermin, 1 mg

J2182

Injection, mepolizumab, 1 mg

J2212

Injection, methylnaltrexone, 0.1 mg

J2315

Injection, naltrexone, depot form, 1 mg

J2323      

Injection, natalizumab, 1 mg

J2326

Injection, nusinersen, 0.1 mg

J2350      

Injection, ocrelizumab, 1 mg

J2353      

Injection, octreotide, depot form for intramuscular injection, 1 mg

J2355

Injection, oprelvekin, 5 mg

J2357      

Injection, omalizumab, 5 mg

J2440

Injection, papaverine HCl, up to 60 mg

J2503      

Injection, pegaptanib sodium, 0.3 mg

J2505

Injection, pegfilgrastim, 6 mg

J2507

Injection, pegloticase, 1 mg

J2562

Injection, plerixafor, 1 mg

J2778      

Injection, ranibizumab, 0.1 mg

J2783

Injection, rasburicase, 0.5 mg

J2786

Injection, reslizumab, 1 mg

J2793

Injection, rilonacept, 1 mg

J2796

Injection, romiplostim, 10 mcg

J2797

Injection, rolapitant, 0.5 mg

J2820

Injection, sargramostim (GM-CSF), 50 mcg

J2840

Injection, sebelipase alfa, 1 mg

J2940

Injection, somatrem, 1 mg

J2941

Injection, somatropin, 1 mg

J3032

Injection, eptinezumab-jjmr, 1 mg

J3095

Injection, telavancin, 10 mg

J3110

Injection, teriparatide, 10 mcg

J3111

Injection, romosozumab-aqqg, 1 mg

J3240

Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial

J3241

Injection, teprotumumab-trbw, 10 mg

J3245

Injection, tirofiban HCl, 12.5 mg

J3262      

Injection, tocilizumab, 1 mg

J3285

Injection, treprostinil, 1 mg

J3304      

Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg

J3316

Injection, triptorelin, extended-release, 3.75 mg

J3357      

Ustekinumab, for subcutaneous injection, 1 mg

J3380      

Injection, vedolizumab, 1 mg

J3385

Injection, velaglucerase alfa, 100 units

J3396      

Injection, verteporfin, 0.1 mg

J3397

Injection, vestronidase alfa-vjbk, 1 mg

J3398

Injection, voretigene neparvovec-rzyl, 1 billion vector genomes

J3399

Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes

J3490

Unclassified drugs

J3590

Unclassified biologics

J3591

Unclassified drug or biological used for ESRD on dialysis

J7169

Injection, coagulation Factor Xa (recombinant), inactivated-zhzo (Andexxa^®), 10 mg

J7170

Injection, emicizumab-kxwh, 0.5 mg

J7175

Injection, Factor X, (human), 1 IU

J7177

Injection, human fibrinogen concentrate (Fibryga^®), 1 mg

J7179

Injection, von Willebrand factor (recombinant), (Vonvendi^®), 1 IU VWF:RCo

J7180

Injection, Factor XIII (antihemophilic factor, human), 1 IU

J7181

Injection, Factor XIII A-subunit, (recombinant), per IU

J7182

Injection, Factor VIII, (antihemophilic factor, recombinant), (Novoeight^®), per IU

J7183

Injection, von Willebrand factor complex (human), Wilate^®, 1 IU VWF:RCO

J7185

Injection, Factor VIII (antihemophilic factor, recombinant) (Xyntha^®), per IU

J7186

Injection, antihemophilic Factor VIII/von Willebrand factor complex (human), per Factor VIII IU

J7187

Injection, von Willebrand factor complex (Humate-P^®), per IU VWF:RCO

J7188

Injection, Von Willebrand factor complex, human, IU

J7189

Factor VIIa (antihemophilic factor, recombinant), per 1 mcg

J7190

Factor VIII (antihemophilic factor, human) per IU

J7191

Factor VIII (antihemophilic factor (porcine)), per IU

J7192

Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified

J7193

Factor IX (antihemophilic factor, purified, non-recombinant) per IU

J7194

Factor IX complex, per IU

J7195

Injection, Factor IX (antihemophilic factor, recombinant) per IU, not otherwise specified

J7196

Injection, antithrombin recombinant, 50 IU

J7197

Antithrombin III (human), per IU

J7198

Antiinhibitor, per IU

J7199

Hemophilia clotting factor, not otherwise classified

J7200

Injection, Factor IX, (antihemophilic factor, recombinant), Rixubis^®, per IU

J7201

Injection, Factor IX, Fc fusion protein, (recombinant), Alprolix^®, 1 IU

J7202

Injection, Factor IX, albumin fusion protein, (recombinant), Idelvion^®, 1 IU

J7203

Injection Factor IX, (antihemophilic factor, recombinant), glycoPEGylated, (Rebinyn^®), 1 IU

J7204

Injection, Factor VIII, antihemophilic factor (recombinant), (Esperoct^®), glycopegylated-exei, per IU

J7207

Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated, 1 IU

J7208

Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated-aucl, (Jivi), 1 IU

J7209

Injection, Factor VIII, (antihemophilic factor, recombinant), (Nuwiq^®), 1 IU

J7311

Injection, fluocinolone acetonide, intravitreal implant (Retisert^®), 0.01 mg^®

J7312

Injection, dexamethasone, intravitreal implant, 0.1 mg

J7313

Injection, fluocinolone acetonide, intravitreal implant (Iluvien^®), 0.01 mg

J7314

Injection, fluocinolone acetonide, intravitreal implant (Yutiq^®), 0.01 mg

J7318      

Hyaluronan or derivative, Durolane^®, for intra-articular injection, 1 mg

J7320      

Hyaluronan or derivative, GenVisc^® 850, for intra-articular injection, 1 mg

J7321      

Hyalgan^® or Supartz, for intra-articular injection, per dose

J7322      

Hyaluronan or derivative, Synvisc^®, for intra-articular injection, per dose

J7323      

Hyaluronan or derivative, Euflexxa^®, for intra-articular injection, per dose

J7324      

Hyaluronan or derivative, Orthovisc^®, for intra-articular injection, per dose

J7325      

Hyaluronan or derivative, Synvisc^® or Synvisc-One^®, for intra-articular injection, 1 mg

J7326      

Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose

J7327      

Hyaluronan or derivative, Monovisc^®, for intra-articular injection, per dose

J7328      

Hyaluronan or derivative, Gelsyn-3^™, for intra-articular injection, 0.1 mg

J7329      

Hyaluronan or derivative, Trivisc^®, for intra-articular injection, 1 mg

J7331

Hyaluronan or derivative, Synojoynt^™, for intra-articular injection, 1 mg

J7332

Hyaluronan or derivative, Triluron^®, for intra-articular injection, 1 mg

J7333

Hyaluronan or derivative, Visco-3^™, for intra-articular injection, per dose

J7351

Injection, bimatoprost, intracameral implant, 1 mcg

J7401

Mometasone furoate sinus implant, 10 mcg

J7518

Mycophenolic acid, oral, 180 mg

J7527

Everolimus, oral, 0.25 mg

J7677

Revefenacin inhalation solution, FDA-approved final product, non-compounded, administered through DME, 1 mcg

J7686

Treprostinil, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 1.74 mg

J8650

Nabilone, oral, 1 mg

J8705

Topotecan, oral, 0.25 mg

J9015

Injection, aldesleukin, per single use vial

J9017

Injection, arsenic trioxide, 1 mg

J9019

Injection, asparaginase (Erwinaze^®), 1,000 IU

J9022      

Injection, atezolizumab, 10 mg

J9023

Injection, avelumab, 10 mg

J9027

Injection, clofarabine, 1 mg

J9034

Injection, bendamustine HCl (Bendeka^®), 1 mg

J9036

Injection, bendamustine hydrochloride, (Belrapzo^™/bendamustine), 1 mg

J9039

Injection, blinatumomab, 1 mcg

J9041

Injection, bortezomib (Velcade^®), 0.1 mg

J9042

Injection, brentuximab vedotin, 1 mg

J9043

Injection, cabazitaxel, 1 mg

J9044

Injection, bortezomib, not otherwise specified, 0.1 mg

J9047

Injection, carfilzomib, 1 mg

J9050

Injection, carmustine, 100 mg

J9055

Injection, cetuximab, 10 mg

J9057

Injection, copanlisib, 1 mg

J9118

Injection, calaspargase pegol-mknl, 10 units

J9119

Injection, cemiplimab-rwlc, 1 mg

J9145      

Injection, daratumumab, 10 mg

J9153

Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine

J9173      

Injection, durvalumab, 10 mg

J9176      

Injection, elotuzumab, 1 mg

J9177

Injection, enfortumab vedotin-ejfv, 0.25 mg

J9179

Injection, eribulin mesylate, 0.1 mg

J9198

Injection, gemcitabine hydrochloride, (Infugem^™), 100 mg

J9203

Injection, gemtuzumab ozogamicin, 0.1 mg

J9204

Injection, mogamulizumab-kpkc, 1 mg

J9205

Injection, irinotecan liposome, 1 mg

J9212

Injection, interferon alfacon-1, recombinant, 1 mcg

J9213

Injection, interferon, alfa-2a, recombinant, 3 million units

J9215

Injection, interferon, alfa-N3, (human leukocyte derived), 250,000 IU

J9216

Injection, interferon, gamma 1-b, 3 million units

J9225

Histrelin implant (Vantas^™), 50 mg

J9226

Histrelin implant (Supprelin^® LA), 50 mg

J9227

Injection, isatuximab-irfc, 10 mg

J9228

Injection, ipilimumab, 1 mg

J9229

Injection, inotuzumab ozogamicin, 0.1 mg

J9246

Injection, melphalan (Evomela^®), 1 mg

J9261

Injection, nelarabine, 50 mg

J9262

Injection, omacetaxine mepesuccinate, 0.01 mg

J9264

Injection, paclitaxel protein-bound particles, 1 mg

J9266

Injection, pegaspargase, per single dose vial

J9269

Injection, tagraxofusp-erzs, 10 mcg

J9271

Injection, pembrolizumab, 1 mg

J9285

Injection, olaratumab, 10 mg

J9299

Injection, nivolumab, 1 mg

J9301

Injection, obinutuzumab, 10 mg

J9303

Injection, panitumumab, 10 mg

J9304

Injection, pemetrexed (Pemfexy^™), 10 mg

J9305

Injection, pemetrexed, NOS,10 mg

J9306

Injection, pertuzumab, 1 mg

J9308      

Injection, ramucirumab, 5 mg

J9309

Injection, polatuzumab vedotin-piiq, 1 mg

J9311      

Injection, rituximab 10 mg and hyaluronidase

J9312

Injection, rituximab, 10 mg

J9313

Injection, moxetumomab pasudotox-tdfk, 0.01 mg

J9325

Injection, talimogene laherparepvec, per 1 million plaque forming units

J9352

Injection, trabectedin, 0.1 mg

J9354

Injection, ado-trastuzumab emtansine, 1 mg

J9355      

Injection, trastuzumab, excludes biosimilar, 10 mg

J9356      

Injection, trastuzumab, 10 mg and hyaluronidase-oysk

J9358

Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

J9395

Injection, fulvestrant, 25 mg

J9400

Injection, ziv-aflibercept, 1 mg

J9999

Not otherwise classified, antineoplastic drugs

Q0138

Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

Q0515

Injection, sermorelin acetate, 1 mcg

Q2026

Injection, Radiesse^®, 0.1 ml

Q2028

Injection, sculptra, 0.5 mg

Q2041      

Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Q2042      

Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Q2043      

Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion

Q2050

Injection, doxorubicin HCl, liposomal, not otherwise specified, 10 mg

Q3027

Injection, interferon beta-1a, 1 mcg for intramuscular use

Q4074

Iloprost, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 20 mcg

Q5101

Injection, filgrastim-sndz, biosimilar, (Zarxio^®), 1 mcg

Q5103      

Injection, infliximab-dyyb, biosimilar, (Inflectra^™), 10 mg

Q5104      

Injection, infliximab-abda, biosimilar, (Renflexis^™), 10 mg

Q5106

Injection, epoetin alfa-epbx, biosimilar, (Retacrit^®) (for non-ESRD use), 1000 units

Q5107

Injection, bevacizumab-awwb, biosimilar, (Mvasi^™), 10 mg

Q5108

Injection, pegfilgrastim-jmdb, biosimilar, (Fulphila^®), 0.5 mg

Q5109

Injection, infliximab-qbtx, biosimilar, (Ixifi^™), 10 mg

Q5110

Injection, filgrastim-aafi, biosimilar, (Nivestym^®), 1 mcg

Q5111

Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca^®), 0.5 mg

Q5112      

Injection, trastuzumab-dttb, biosimilar, (Ontruzant^®), 10 mg

Q5113      

Injection, trastuzumab-pkrb, biosimilar, (Herzuma^®), 10 mg

Q5114      

Injection, Trastuzumab-dkst, biosimilar, (Ogivri^™), 10 mg

Q5115

Injection, rituximab-abbs, biosimilar, (Truxima^®), 10 mg

Q5116      

Injection, trastuzumab-qyyp, biosimilar, (Trazimera^™), 10 mg

Q5117      

Injection, trastuzumab-anns, biosimilar, (Kanjinti^™), 10 mg

Q5118

Injection, bevacizumab-bvcr, biosimilar, (Zirabev^®), 10 mg

Q5119

Injection, rituximab-pvvr, biosimilar, (Ruxience^®), 10 mg

Q5120

Injection, pegfilgrastim-bmez, biosimilar, (Ziextenzo^®), 0.5 mg

Q5121

Injection, infliximab-axxq, biosimilar, (Avsola^™), 10 mg

Q9991

Injection, buprenorphine extended-release (Sublocade^™), less than or equal to 100 mg

Q9992

Injection, buprenorphine extended-release (Sublocade), greater than 100 mg

S0145

Injection, PEGylated interferon alfa-2A, 180 mcg per ml

Medicare (individual)

1-800-929-9224

provider.healthnetcalifornia.com

provider_services@healthnet.com

Medicare (employer group)

1-800-929-9224

provider.healthnet.com

provider_services@healthnet.com