21-419 New Medications Added to the Prior Authorization Requirements List

Date: 06/16/21

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

Part B medications requiring prior authorization

Refer to the table below for updated Part B medications requiring prior authorization.

Effective April 1, 2021

The following Part B medications were updated based on new HCPCS codes issued by the Centers for Medicare & Medicaid Services, effective April 1, 2021:

Additions

Code	Description
C9074	Injection, lumasiran, 0.5 mg
J1427	Injection, viltolarsen, 10 mg
J1554	Injection, immune globulin (asceniv), 500 mg
J7402	Mometasone furoate sinus implant, (sinuva), 10 micrograms
Q2053	Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose

Effective August 1, 2021

The authorization requirements for the following Part B medications will be updated effective August 1, 2021:

Additions

Code	Description
J3358	ustekinumab, for intravenous injection, 1 mg
J9035	Injection, bevacizumab, 10 mg
J9210	emapalumab-lzsg, 1 mg

 

Deletions

Code	Description
J0604	cinacalcet, oral, 1 mg
J8499	Prescription drug, oral, non chemotherapeutic, nos1
J9144	Injection, daratumumab, 10 mg and hyaluronidase-fihj
J9358	Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

_{¹NOS – not otherwise specified}

View prior authorization requirements online

Access the prior authorization list, request forms and validation tools with these steps:

1. Go to the provider website.
2. Scroll down the page and select Resources for you, then select Pharmacy.

To confirm whether a Part B medication requires prior authorization or step therapy, refer to the Pre-Auth Needed Tool by following these steps:

       3.Use the steps above and select Medicare Pre-Auth. Answer questions provided, then enter the code you would like to check.

You can also go to the Health Net Advantage website and select For Providers at the top of the page. It will reroute you to step 2 above and you can continue to follow the steps.

Additional information

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

Line of Business	Telephone Number	Provider Portal	Email Address
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