24-489 Medical Medication Prior Authorization Changes and NIA Name Change
Date: 05/24/24
Get prior authorization for medical benefit drugs listed in this update
The following prior authorization (PA) changes apply to Medi-Cal fee-for-service physicians and other providers.
CMS New HCPCS
The below medical benefit medications require PA per new HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS).
Effective January 1, 2024
Code | Description | Brand/reference |
|---|---|---|
C9160 | Injection, daxibotulinumtoxina-lanm, 1 unit | Daxxify® |
C9161 | Injection, aflibercept HD, 1 mg | Eylea® |
C9162 | Injection, avacincaptad pegol, 0.1 mg | Izervay® |
C9163 | Injection, talquetamab-tgvs, 0.25 mg | TalveyTM |
C9165 | Injection, elranatamab-bcmm, 1 mg | ElrexfioTM |
J0217 | Injection, velmanase alfa-tycv, 1 mg | Lamzede® |
J1246 | N/A | Unituxin® |
J1304 | Injection, tofersen, 1 mg | Qalsody® |
J1412 | Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes | Roctavian® |
J1413 | Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose | ElevidysTM |
J2508 | Injection, pegunigalsidase alfa-iwxj, 1 mg | Elfabrio® |
J3401 | Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml | VyjuvekTM |
J9286 | Injection, glofitamab-gxbm, 2.5 mg | ColumviTM |
J9321 | Injection, epcoritamab-bysp, 0.16 mg | EpkinlyTM |
J9324 | Injection, pemetrexed (Pemrydi RTU), 10 mg | Pemrydi RTU® |
J9333 | Injection, rozanolixizumab-noli, 1 mg | Rystiggo® |
J9334 | Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc | Vyvgart® Hytrulo |
Q5132 | Injection, adalimumab-afzb (Abrilada), biosimilar, 10 mg | Abrilada® |
CMS New HCPCS, effective April 1, 2024
Code | Description | Brand/reference |
|---|---|---|
C9166 | Injection, secukinumab, IV, 1 mg | Cosentyx® |
C9167 | Injection, apadamtase alfa, 10 units | AdzynmaTM |
C9168 | Injection, mirikizumab-mrkz, 1 mg | OmvohTM |
J0177 | Injection, aflibercept HD, 1 mg | Eylea HD® |
J0589 | Injection, daxibotulinumtoxina-lanm, 1 unit | Daxxify® |
J1203 | Injection, cipaglucosidase alfa-atga, 5 mg | PombilitiTM |
J1323 | Injection, elranatamab-bcmm, 1 mg | ElrexfioTM |
J2277 | Injection, motixafortide, 0.25 mg | Aphexda® |
J2782 | Injection, avacincaptad pegol, 0.1 mg | Izervay® |
J3055 | Injection, talquetamab-tgvs, 0.25 mg | TalveyTM |
J9376 | Injection, pozelimab-bbfg, 1 mg | VeopozTM |
Q5133 | Injection, tocilizumab-bavi (Tofidence), biosimilar, 1 mg | TofidenceTM |
Q5134 | Injection, natalizumab-sztn (Tyruko), biosimilar, 1 mg | Tyruko® |
PA additions, changes and deletions
View the tables below for PA requirements changes for Health Net and Community Health Plan of Imperial Valley physicians and other providers.
OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT): PA Additions, effective August 1, 2024 | |
|---|---|
Requirement | Comments |
Benlysta® | J0490, injection, belimumab, 10 mg
|
Trodelvy® | J9317, Injection, sacituzumab govitecan-hziy, 2.5 mg |
CasgevyTM | HCPCS unassigned; J3590, Unclassified biologicals |
PA Removals, effective immediately
Requirement | Comments |
|---|---|
Blenrep | J9037, injection, belantamab mafodotin-blmf, 0.5 (discontinued) |
Feraheme | Q0138, Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) (discontinued) |
Makenna | J1726, Injection, hydroxyprogesterone caproate, (makena), 10 mg |
Sunlenca® | J3490, injection, lenacapavir for the treatment of human immunodeficiency virus type 1
|
NIA is now called Evolent
On January 1, 2024, National Imaging Associates, Inc. (NIA) changed its name to Evolent Specialty Services, Inc. (Evolent). Evolent provides prior authorization for advanced imaging and cardiac imaging requests.
This change should have no immediate impact on your experience or on the care of your members, and you do not need to take any action. The portals, links and processes that you currently use will remain in use. Later this year, these online resources will redirect to a new experience reflecting the company’s new name and brand.
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, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Imperial County.