News
23-1405 New CMS HCPCS Codes and Prior Authorization Changes
Date: 11/29/23
Palliative care requires prior authorization for D-SNP members starting January 1, 2024
Wellcare By Health Net (Health Net) is making changes to the Medicare Advantage HMO/PPO prior authorization (PA) requirements as outlined in the table below. These changes apply to Direct Network physicians, hospitals, ancillary providers, and non-delegated fee-for-service participating physician groups.
For members who are dually eligible (Medi-Cal secondary coverage), services covered under their Medicare plan follow Medicare authorization requirements. Services that are only covered under the member’s Medi-Cal benefits should follow the member’s Medi-Cal authorization requirements.
Effective October 1, 2023
The below Part B medications require PA per new HCPCS codes issued by the Centers for Medicare & Medicaid Services.
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 |
Cortrophin® |
J0889 |
Daprodustat, oral, 1 mg, (for ESRD |
JesduvroqTM |
J2781 |
Injection, pegcetacoplan, intravitreal, |
Syfovre® |
J7214 |
Injection, Factor VIII/von Willebrand factor complex, recombinant (Altuviiio), per Factor VIII IU |
Hemophilia factors: AltuviiioTM |
J9051 |
Injection, bortezomib (MAIA), not therapeutically equivalent to J9041, 0.1 mg |
Velcade® |
J9064 |
Injection, cabazitaxel (Sandoz), not therapeutically equivalent to J9043, 1 mg |
generic for Jevtana® |
J9345 |
Injection, retifanlimab-dlwr, 1 mg |
ZynyzTM |
Outpatient pharmaceuticals (submitted under Medical Benefit)
Medication newly approved by the U.S. Food and Drug Administration (FDA) requires PA, effective immediately.
Requirement |
Comments |
---|---|
ElevidysTM |
delandistrogene moxeparvovec-rokl |
PA Additions, effective January 1, 2024
View the table below for PA requirement changes for Medicare Advantage HMO/PPO physicians and other providers.
Outpatient Procedures, Services or Equipment
Requirement |
Comments |
---|---|
Palliative care |
Applies to D-SNP members only. |
Additional information
If you have questions regarding the information contained in this update, contact the Provider Services Center at
800-929-9224.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.