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23-1236 Prior Authorization Changes Effective January 1, 2024

Date: 10/23/23

Get prior authorization for medical benefit drugs and services listed in this update

Below are prior authorization (PA) changes for commercial (HMO/POS/HSP, EPO, PPO), Ambetter HMO/PPO and Medi-Cal fee-for-service physicians and other providers.

CMS New HCPCS

The below medical benefit medications require PA for all lines of business per new HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS).

Effective October 1, 2023

CodeDescriptionBrand/reference

C9155

Injection, epcoritamab-bysp, 0.16 mg

EpkinlyTM

C9157

Injection, tofersen, 1 mg

QalsodyTM

J0801

Injection, corticotropin (Acthar Gel), up to 40 units

HP Acthar®

J0802

Injection, corticotropin (ANI), up to 40 units

Cortrophin®

J0889

Daprodustat, oral, 1 mg, (for ESRD on dialysis)

JesduvroqTM

J2781

Injection, pegcetacoplan, intravitreal, 1 mg

Syfovre®

J7214

Injection, Factor VIII/von Willebrand factor complex, recombinant (Altuviiio), per Factor VIII IU (prior authorization required for commercial members only)

Hemophilia factors: AltuviiioTM

J9051

Injection, bortezomib (MAIA), not therapeutically equivalent to J9041, 0.1 mg (prior authorization required for Medi-Cal members ages 0–20 only)

Velcade®

J9064

Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043, 1 mg

generic for Jevtana®

J9345

Injection, retifanlimab-dlwr, 1 mg

ZynyzTM

PA Additions and Deletions, effective January 1, 2024

View the tables below for PA requirement changes for Health Net Medi-Cal fee-for-service physicians and other providers.

For Commercial (HMO/POS/HSP, EPO, PPO) only

OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT):

PA Deletions, effective January 1, 2024

Requirement

Comments

Sublocade™

HCPCS:

  • Q9991 Injection, buprenorphine extended-release (SUBLOCADE), less than or
    equal to 100 mg
  • Q9992 Injection, buprenorphine extended-release (SUBLOCADE), greater than
    100 mg

For Medi-Cal Only

INPATIENT SERVICES

PA Additions, effective January 1, 2024

Requirement

Comments

Long-term care nursing facility admissions

  • Required for pediatric members under age 21. Note: This is already a requirement for adults over age 21.
  • Contact the Health Net Long-Term Care Intake Line via fax to notify Health Net of its Medi-Cal members' admissions to long-term nursing facilities. Fax: 855-851-4563 or
    call 800-453-3033 to check the status of your request.

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the provider portal.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

 

 

 

 

 

 



Last Updated: 10/23/2023