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 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	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.