24-1134 2025 Prior Authorization Changes to Medical Benefit Medications
Date: 10/22/24
Learn which drugs have been added, changed or removed from prior authorization requirements
The following update includes prior authorization (PA) changes for Commercial (HMO, Point of Service (POS), PPO), Ambetter HMO/PPO and Medi-Cal fee-for-service physicians and other providers. These changes all apply to outpatient pharmaceuticals (submitted under the medical benefit).
Deletions, effective January 1, 2025
The following no longer require PA.
Requirement | Code and description |
BCG Intravesical | J9030 BCG live intravesical instillation, 1 mg |
Nuzyra® | J0121 Injection, omadacycline, 1 mg |
Sandostatin® | J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg |
SensiparTM | J0604 Cinacalcet, oral, 1 mg, (for end-stage renal disease on dialysis) |
Changes, effective January 1, 2025
The following are changes to existing PA requirements.
Requirement | Code and description | Comments |
Darzalex® |
| Changed to Darzalex/Darzalex Faspro® Codes currently require authorization |
NyvepriaTM | Q5122 Injection, pegfilgrastim-apgf, biosimilar, 0.5 mg) | Changed to preferred |
Ziextenzo® | Q5120 Injection, pegfilgrastim-bmez, biosimilar, 0.5 mg) | Changed to nonpreferred |
Additions, effective January 1, 2025
The following require PA.
Requirement | Code and description | Comments |
Anktiva® | J9999, Not otherwise classified, antineoplastic drugs | N/A |
BeqvezTM | J3590 Unclassified biologics | N/A |
BkemvTM | J1300, Injection, eculizumab, 10 mg | Code currently requires authorization: Soliris® |
ImdelltraTM | J3590, Unclassified biologics | N/A |
Imlygic® | J9325, Injection, talimogene laherparepvec, | Gene therapy |
Ketalar® | J3490, Unclassified drugs | N/A |
LenmeldyTM | J3590, Unclassified biologics | N/A |
Leukine® | J2820, Injection, sargramostim (GM-CSF), 50 mcg | N/A |
Tevimbra® | J3490, Unclassified drugs | PD 1 inhibitor |
Tyenne® | J3262, Injection, tocilizumab, 1 mg | Code currently requires authorization: Actemra® |
Commercial and Ambetter only
The below PA requirement addition applies to Health Net Commercial and Ambetter HMO/PPO physicians and other providers.
Changes, effective January 1, 2025
Requirement | Code and description | Comments |
ByoovizTM | Q5124, Injection, ranibizumab-nuna, biosimilar, | Added to Ranibizumab agents Code currently requires authorization: biosimilar |
Avsola® | Q5121, Injection, infliximab-axxq, biosimilar, 10mg | Added as nonpreferred infliximab agent Code currently requires authorization: biosimilar |
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
Line of business | Phone number | Email address |
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medi-Cal (including CS and ECM providers) | N/A | |
Behavioral Health providers | N/A |
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.