26-1202 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 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
- Change, effective immediately.
- Additions, effective January 1, 2027.
- Removals, effective January 1, 2027.
How to access PA requirements
To access the LA-DHS PA requirements, go to Prior Authorizations and select Medi-Cal Los Angeles County Department of Human Services (LA-DHS) Participating Physician Groups.
Change, 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™ | N/A |
Outpatient pharmaceuticals: Pegfilgrastim − Ennumo™ | N/A |
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.
- Assisted Living Facility Transitions
- Personal Care and Homemaker Services
- Short-Term Post-Hospitalization Housing
Need help? Contact us
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center at 800-675-6110.
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.
For Medi-Cal, this information applies to Los Angeles (LA-DHS).