23-1446 Prior Authorization Changes Effective March 1, 2024
Date: 12/20/23
Get prior authorization for medical benefit drugs and services listed in this update
The following pages have prior authorization (PA) changes for commercial (HMO/POS, PPO), Ambetter HMO/PPO and Medi-Cal fee-for-service physicians and other providers.
Medications Newly approved by the FDA require PA effective immediately
The following medication newly approved by the U.S. Food and Drug Administration (FDA) requires prior authorization.
Requirement | Comments |
|---|---|
ElevidysTM | Infusion, gene therapy, single dose |
PA additions, changes and deletions, effective March 1, 2024
View the tables below for PA requirement changes for Health Net Medi-Cal fee-for-service physicians and other providers.
OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT):
PA Additions, effective March 1, 2024
Requirement | Comments |
|---|---|
Arzerra® | J9302, injection, ofatumumab, 10 mg |
Novantrone® | J9293, injection, mitoxantrone hydrochloride, per 5 mg |
Signifor® LAR | J2502, injection, pasireotide long acting, 1 mg |
Valstar® | J9357, injection, valrubicin, intravesical, 200 mg |
PA Change, effective March 1, 2024
Requirement | Comments |
|---|---|
Vegzelma® |
|
FOR MEDI-CAL ONLY
OUTPATIENT SERVICES
PA Additions, effective March 1, 2024 – Leg stent bridge
Procedure Code | Description |
|---|---|
37220 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty |
37221 | Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
37224 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty |
37225 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed |
37226 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
37227 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed |
37228 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty |
37229 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed |
37230 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed |
37231 | Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed |
PA Deletions, effective March 1, 2024
Service type | Description |
|---|---|
Echocardiogram | Currently managed by NIA:
|
Additional information
If you have questions regarding the information in this update, contact the applicable Health Net Provider Services Center within 60 days, by phone or the Health Net provider portal.
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 Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.