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23-1238 Prior Authorization Changes Effective January 1, 2024

Date: 10/23/23

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

The below medical benefit medications require prior authorization (PA) per new HCPCS codes issued by the Centers for Medicare & Medicaid Services. This applies to the Los Angeles County Department of Health Services (LA-DHS).

Effective October 1, 2023

Code	Description	Brand/ reference
C9155	Injection, epcoritamab-bysp, 0.16 mg	Epkinly^TM
C9157	Injection, tofersen, 1 mg	Qalsody^TM
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)	Jesduvroq^TM
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	Zynyz^TM

PA Additions, effective January 1, 2024

View the table below for PA requirement changes.

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 Hospitals/Clinics.

For Medi-Cal, this information applies to Los Angeles (LA-DHS).

Last Updated: 10/23/2023