24-1135 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
View the tables below for prior authorization (PA) requirements changes for the Los Angeles County Department of Health Services (LA-DHS) participating physician groups (PPGs). These changes all apply to outpatient pharmaceuticals (submitted under the medical benefit).
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, per 1 million plaque forming units | 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, | Code currently requires authorization: Actemra® |
Changes, effective January 1, 2025
The following are changes to existing PA requirements.
Requirement | Code and description | Comments |
Darzalex® |
| Changed to Darzalex/Darzalex Faspro® |
NyvepriaTM | Q5122 Injection, pegfilgrastim-apgf, biosimilar, 0.5 mg) | Changed to preferred |
Ziextenzo® | Q5120 Injection, pegfilgrastim-bmez, biosimilar, 0.5 mg) | Changed to nonpreferred |
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 |
SensiparTM | J0604 Cinacalcet, oral, 1 mg, (for end-stage renal disease on dialysis) |
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.
If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800-675-6110. Behavioral health providers can call 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
For Medi-Cal, this information applies to Los Angeles (LA-DHS).