21-750 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.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

Drugs that require prior authorization now andother changes that start January 1, 2022

View the table below for prior authorization (PA) requirement changes for Health Net* and CalViva Health Medi-Cal fee-for-service providers.

Medications requiring PA effective immediately

• Aduhelm^TM, 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.

Medi-Cal fee-for-service PA Changes

Below are PA requirement changes for Medi-Cal fee-for-service providers. “New” indicates new requirement, “Existing” indicates current requirement and “N/A” indicates not applicable.

Requirement	Comments	Adult members ages 21 and over	Pediatric members under age 21
Additions, effective January 1, 2022
Community Supports Asthma remediation Environmental accessibility adaptations (home modifications) Housing transition navigation services Housing tenancy and sustaining services Recuperative care (medical respite) Meals/medically tailored meals Sobering centers	Additional information will be available in the Provider Operations Manual regarding specific services available in your county.	New	New
Enhanced care management (ECM)		New	ew
Major organ transplant	Fax requests to the Transplant Team at: 833-769-1141. Transplant evaluations and procedures, including, but not limited to, evaluation, transplant consult visits, donor search, and transplant procedure.	New	New
Outpatient Pharmaceuticals (submitted under Medical Plan)	Abecma®, EmpaveliTM, Fensolvi®, Nexviazyme®, Sotradecol®	New	New
Deletions, effective January 1, 2022
Testing and in-office procedures performed by pediatric sub-specialists	Procedures, Services or Equipment specifically named on the authorization list continue to require authorization.	N/A	Existin
Wheelchair repairs and accessories for adult members with billed charges under $1,500	Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment.	Existing	N/A

Additional information

Providers are encouraged to access the 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 CalViva Health at 888-893-1569.