21-295 New Medications Added to the Prior Authorization Requirements List
Date: 04/28/21
Medications requiring PA effective immediately
Refer to the table below for updated Part B medications requiring prior authorization (PA). These medications were updated based on new HCPCS codes issued by the Center for Medicare and Medicaid Services (CMS), effective January 1, 2021. The full list of Part B medications are in the Prior Authorization Requirements List online.
Additions
Code | Description |
|---|---|
C9069 | Injection, belantamab mafodontin-blmf, 0.5 mg |
C9070 | Injection, tafasitamab-cxix, 2 mg |
C9071 | Injection, viltolarsen, 10 mg |
C9072 | Injection, immune globulin (asceniv), 500 mg |
C9073 | Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
J1823 | Injection, inebilizumab-cdon, 1 mg |
J7212 | Factor viia (antihemophilic factor, recombinant)-jncw (sevenfact), 1 microgram |
J7352 | Afamelanotide implant, 1 mg |
J9144 | Injection, daratumumab, 10 mg and hyaluronidase- fihj |
J9223 | Injection, lurbinectedin, 0.1 mg |
J9281 | Mitomycin pyelocalyceal instillation, 1 mg |
J9316 | Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg |
J9317 | Injection, sacituzumab govitecan-hziy, 2.5 mg |
Q5122 | Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg |
S0013 | Esketamine, nasal spray, 1 mg |
Deletions | |
C9062 | Injection, daratumumab 10 mg and hyaluronidase-fihj |
C9064 | Mitomycin pyelocalyceal instillation, 1 mg |
C9066 | Injection, sacituzumab govitecan-hziy, 10 mg |
View PA requirements online
Access PA lists, request forms and validation tools with these steps:
- Go to the Health Net provider website.
- Pre-log in, select Working with Health Net. Under Additional Resources, select Services Requiring Prior Authorization.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
Medicare (individual) | 1-800-929-9224 | provider_services@healthnet.com | |
Medicare (employer group) | 1-800-929-9224 | provider_services@healthnet.com |