26-1199 Updates to Prior Authorization Requirements
Date: 10/27/26
Review changes, effective immediately through January 1, 2027
Prior authorization (PA) requirement changes apply to certain services, procedures, equipment and outpatient medications.
These updates reflect new CPT/HCPCS codes issued by the Centers for Medicare & Medicaid Services (CMS) and other changes implemented by Health Net, on behalf of CalViva Health, for select services and medications.
What providers need to do
- Review the code lists below for changes affecting your practice.
- Submit PA requests for services requiring authorization starting on the effective date.
- Verify member eligibility and benefits before providing services. Changes to PA requirements do not constitute, imply or confirm benefit coverage, as authorization requirements are independent of coverage determinations.
- Use current PA requirements when submitting requests.
Key effective dates
- Changes, effective immediately.
- Additions, effective January 1, 2027.
- Removals, effective January 1, 2027.
Avoid appeals and grievances cases related to prior authorization
Incomplete or incorrect prior authorization requests may result in member appeals or grievances.
To help avoid delays and follow-up requests:
- Submit complete and accurate prior authorization requests.
- Follow the correct requirements and response time frames for the applicable line of business.
For more information and resources on appeals and grievances and prior authorization:
- Go to Provider Library and select Medi-Cal.
- Open the Provider Manual and navigate to the following sections:
- Appeals, Grievances and Disputes
- Prior Authorization Requirements
How to access PA requirements
Use one of these options:
- Go to Prior Authorizations and select Fresno, Kings and Madera counties – CalViva Health.
- Go to Provider Library > Medi-Cal > Prior Authorization Requirements.
Changes, effective immediately
Changes to the preferred or non-preferred status for the biosimilar medications listed below are effective immediately.
Category | Change |
|---|---|
Denosumab (Prolia®, Xgeva® and biosimilars) | Non-preferred (bone metastasis): Aukelso™, Bomyntra®, Jubereq®, Osenvelt®, Oziltus®, Wyost®, Xbryk®, Xgeva Preferred (bone metastasis): Bilprevda®, Xtrenbo™ Non-preferred (osteoporosis): Boncresa™, Bonsaya™, Conexxence®, Jubbonti®, Ospomyv™, Osvyrti®, Ponlimsi™, Prolia, Stoboclo® Preferred (osteoporosis): Bildyos®, Enoby™ |
Ustekinumab agents | Non-preferred: Imuldossa®, Starjemza™, Stelara®, unbranded Pyzchiva®, Wezlana™ Preferred: Brand Pyzchiva, Otulfi®, Selarsdi™, Steqeyma®, Yesintek™ |
Additions, effective January 1, 2027
PA is required for the following, effective January 1, 2027.
Category | CPT/HCPCS code |
|---|---|
Outpatient pharmaceuticals: Gene therapy − Kresladi™ | Not applicable |
Outpatient pharmaceuticals: Pegfilgrastim − Ennumo™ | Not applicable |
Outpatient pharmaceuticals: Yondelis® | J9352 |
Scalp cooling | 97007, 97008, 97009 |
Removals, effective January 1, 2027
The following discontinued Community Supports services no longer require PA, effective January 1, 2027. For more information, please refer to provider update 26-990, Changes to Community Supports Services, Effective January 1, 2027.
- Assisted Living Facility Transitions
- Personal Care and Homemaker Services
- Short-Term Post-Hospitalization Housing
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral Health providers can call 844-966-0298.
CPT Copyright 2025 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
This information applies to Physicians and Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.