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23-1447 Prior Authorization Changes Effective March 1, 2024

Date: 12/20/23

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

As a reminder, California Health & Wellness Plan members in Amador, Calaveras, Inyo, Mono, and Tuolumne counties will transition to Health Net Community Solutions, Inc., (Health Net) and members in Imperial County will transition to Community Health Plan of Imperial Valley on January 1, 2024. As a result of this transition, we want to ensure you have the most current prior authorization (PA) requirements that are effective March 1, 2024.

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®

  • Q5129, injection, bevacizumab-adcd, biosimilar, 10 mg
  • No longer requires PA for ophthalmologists

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:

  • Stress echocardiography
  • Transthoracic echocardiography (TTE)
  • Transesophageal echocardiography (TEE)

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 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 Amador, Calaveras, Inyo, Mono, Imperial, and Tuolumne counties.



Last Updated: 12/19/2023