21-748 Prior Authorization! Find Out What's New or Changing
Date: 10/27/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
Drugs that require prior authorization now and other changes that start January 1, 2022
Health Net is implementing changes to the Cal MediConnect Plan (Medicare-Medicaid Plan) fee-for-service prior authorization (PA) requirements.
Medications requiring PA effective immediately
- AduhelmTM, approved by the U.S. Food and Drug Administration (FDA) on June 7, 2021.
- New injectable medication HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) on July 1, 2021:
o Amondys 45TM | o Danyelza® | o MargenzaTM | o Pepaxto® |
- New injectable medication HCPCS codes issued by CMS on October 1, 2021:
o Cosela TM | o Jemperli® | o Rybrevant TM | o Zynlonta® |
Go online for current PA requirements
Follow the steps below to find out if any procedures, services or equipment need PA:
1 Go to the Provider Portal.
2 Before logging in, select Working with Health Net > Additional Resources > Services Requiring Prior Authorization.
3 After logging in, select Working with Health Net > Contractual > Services Requiring Prior Authorization.
Cal MediConnect PA Changes
Below are PA requirement changes for Cal MediConnect medical benefits plan.
| Requirement | Comments |
|---|---|
| Additions, effective January 1, 2022 | |
Community Supports
|
|
| Outpatient Pharmaceuticals (submitted under Medical Plan) | Abecma®, EmpaveliTM, Fensolvi®, Nexviazyme®, Sotradecol®
|
Deletions, effective January 1, 2022 | |
Wheelchair repairs and accessories under $250 in billed charges | Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment |
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 within 60 days, by phone or through the Health Net provider website.
Line of Business | Telephone Number | Email Address |
|---|---|---|
Cal MediConnect – Los Angeles County | 1-855-464-3571 | |
Cal MediConnect – San Diego County | 1-855-464-3572 |