24-1136 2025 Prior Authorization Changes to Medical Benefit Medication
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 Medi-Cal fee-for-service physicians and other providers servicing Community Health Plan of Imperial Valley members. 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
If you have questions regarding the information contained in this update, contact Community Health Plan of Imperial Valley at 833-236-4141. Behavioral Health providers can call 844-966-0298.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial county.