23-1240 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 (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 and CalViva Health 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. Contact the Long-Term Care Intake Line – phone: 800-453-3033; |
Additional information
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.