23-1237 Prior Authorization Changes Effective January 1, 2024

Date: 10/23/23

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

As a reminder, California Health & Wellness Plan (CHWP) members in Amador, Calaveras, Inyo, Mono, and Tuolumne counties will transition to Health Net Community Solutions, Inc., (Health Net) and members in Imperial County will transition to Community Health Plan of the Imperial Valley (CHPIV) on January 1, 2024. As a result of this transition, we want to ensure you have the most current prior authorization (PA) requirements as of January 1, 2024.

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

Code	Description	Brand/ 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®
J9051	Injection, bortezomib (MAIA), not therapeutically equivalent to J9041, 0.1 mg (prior authorization required for 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, effective January 1, 2024

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

Inpatient Services

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. Submit a prior authorization request to Health Net. 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 Medi-Cal Provider Services Center at 800-675-6110.

 

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 Amador, Calaveras, Imperial, Inyo, Mono, and Tuolumne counties.