21-784 Prior Authorization! Find Out What’s New or Changing
Date: 11/05/21
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
Wellcare By Health Net (Health Net) is making changes to the Medicare Advantage HMO prior authorization (PA) requirements. The PA changes apply to Direct Network physicians, hospitals and ancillary providers, as well as non-delegated fee-for-service participating physician groups.
Part B Medications that require PA 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:
Code | Description |
|---|---|
C9075 | Injection, casimersen, 10 mg |
C9076 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
C9077 | Injection, cabotegravir and rilpivirine, 2 mg/3 mg |
C9079 | Injection, evinacumab-dgnb, 5 mg |
C9080 | Injection, melphalan flufenamide HCl, 1 mg |
J0224 | Injection, lumasiran, 0.5 mg |
J1951 | Injection, leuprolide acetate for depot suspension (Fensolvi), 0.25 mg |
J9314 | Injection, romidepsin, nonlyophilized (e.g., liquid), 0.1 mg |
J9348 | Injection, naxitamab-gqgk, 1 mg |
J9353 | Injection, margetuximab-cmkb, 5 mg |
Q5123 | Injection, rituximab-arrx, biosimilar, (Riabni), 10 mg |
- New injectable medication HCPCS codes issued by CMS on October 1, 2021:
Code | Description |
|---|---|
C9081 | Idecabtagene vicleucel, up to 460 million autologous anti-BCMA CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
C9082 | Injection, dostarlimab-gxly, 100 mg |
C9083 | Injection, amivantamab-vmjw, 10 mg |
C9084 | Injection, loncastuximab tesirine-lpyl, 0.1 mg |
J1305 | Injection, evinacumab-dgnb, 5 mg |
J1426 | Injection, casimersen, 10 mg |
J1448 | Injection, trilaciclib, 1 mg |
J9247 | Injection, melphalan flufenamide, 1 mg |
J9318 | Injection, romidepsin, nonlyophilized, 0.1 mg |
J9319 | Injection, romidepsin, lyophilized, 0.1 mg |
Q2054 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose |
Medicare Advantage HMO PA Changes
Below are PA requirement changes for the Medicare Advantage HMO medical benefits plan for direct network providers.
Additions, effective January 1, 2022
Requirement | Comments |
|---|---|
| Behavioral health and substance abuse | Transcranial magnetic stimulation (TMS) |
| Transcatheter implantation of wireless pulmonary artery pressure | N/A |
Part B Medications
Code | Description |
|---|---|
J0882 | Injection, darbepoetin alfa, 1 microgram (for ESRD on dialysis) |
J9144 | Injection, daratumumab, 10 mg and hyaluronidase-fihj |
J9358 | Injection, fam-trastuzumab deruxtecan-nxki, 1 mg |
Q4081 | Injection, epoetin alfa, 100 units (for ESRD on dialysis) |
Changes, effective January 1, 2022
Requirement | Comments |
|---|---|
Durable medical equipment (DME) | Oxygen is changed to oxygen concentrators (Note: Oxygen tanks will no longer require prior authorization.) |
Deletions, effective January 1, 2022
Requirement | Comments |
|---|---|
Wheelchair and accessories | Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment |
Wound vacuum | Listed under Durable medical equipment (DME), Outpatient Procedures, Services or Equipment |
Go online for current PA requirements
Use these directions to access current PA requirements and to submit a request:
For members enrolled in… | Follow these steps… |
|---|---|
Employer group Medicare Advantage (MA) HMO |
|
Individual MA HMO and Special Needs Plan (SNP) |
|
Additional information
If you have questions regarding the information contained in this update, contact the applicable Provider Services Center within 60 days as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
Medicare (individual) (Wellcare By Health Net) | 1-800-929-9224 |
| |
Medicare (employer group) (Wellcare By Health Net) | 1-800-929-9224 |
|