26-630 Updates to Prior Authorization Requirements

Date: 05/20/26

Medi-Cal incontinence supplies change, effective now, and new codes, effective April 1, 2026

This provider update includes prior authorization (PA) requirement changes for Commercial (Individual & Family Plan (Ambetter HMO/PPO) and Employer Group HMO/POS and PPO), Medi-Cal and Wellcare By Health Net (Health Net) lines of business.

These changes apply to services, procedures, equipment and outpatient pharmaceuticals (submitted under the medical benefit).

Changes are listed in the following order:

• Change to incontinence supplies authorization enforcement for Medi-Cal plans
• New CPT and HCPCS codes requiring authorization, effective April 1, 2026

In the tables below, “X” applies to the lines of business indicated; N/A refers to “not applicable.”

How to access prior authorization requirements

Access the PA requirements via either option below:

• Go to Prior Authorizations and select Medi-Cal Fee-for-Service Health Net, Commercial – California, or Medicare – California.
• Go to the Provider Library >  select a line of business > Prior Authorization Requirements.

Change, effective immediately

PA is only required for incontinence supplies beyond 186 units per calendar month or the $165 per month benefit limitation — whichever is greater.

Medicare	HMO/POS/PPO	Medi-Cal	Category	HCPCS code
N/A	N/A	X	Incontinence supplies	T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4533, T4543

 

Additions, effective April 1, 2026

The below services, procedures, equipment and outpatient pharmaceuticals require PA as of April 1, 2026, per new CPT and HCPCS codes issued by the Centers for Medicare & Medicaid Services.

Medicare	HMO/POS/PPO	Medi-Cal	Category	CPT/HCPCS code
X	N/A	X – PA required for members under age 21	Advanced imaging − CT	G0680
X	X	X	Genetic testing	0616U, 0617U, 0618U, 0619U, 0620U, 0621U, 0622U, 0623U, 0624U, 0625U, 0626U, 0627U, 0628U, 0629U, 0630U
X	X	X	Neuro and spinal cord stimulators, including procedures	C8007, C8008, C8011, C8012,
X	X	X	Orthotics – Custom	A8005, A8006
X	N/A	N/A	Orthotics	L2221
X	N/A	N/A	Part B medications	C9818, J9278
X	X	X	Outpatient pharmaceuticals − Inlexzo®	J9183
X	X	X	Outpatient pharmaceuticals − Keytruda Qlex®	J9277
X	X	X	Outpatient pharmaceuticals − Lynozyfic™	J9601
X	X – PA not required for urology/ hematology	X – PA not required for urology/ hematology	Outpatient pharmaceuticals − Camcevi ETM®	J9003
X	X	X	Outpatient pharmaceuticals − Immune Globulin Yimmugo®	J1553
X	X	X	Outpatient pharmaceuticals − Denosumab agents	Q5161, Q5162
X	X	X	Outpatient pharmaceuticals gene therapy − Car-T Papzimeos™	J3404
X	X	X	Outpatient pharmaceuticals gene therapy − Itvisma®	C9309
N/A	X	X	Orthotics − custom	A8005, A8006
X	X	X	Proprietary laboratory analyses	0614U, 0615U
X	X – items exceeding $2,500 in billed charges	X – PA required for members under age 21	Prosthetics	L5992
X	X	X	Skin substitutes and biologicals	A2040, A2041, A2042, A2043, A2044, A2045, G0681, G0682, G0683, G0684, Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440

 

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Need help? Contact us

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by phone or through the Health Net provider portal. Behavioral health providers can call 844-966-0298.

Provider Services

Line of business	Phone number	Email
Ambetter from Health Net IFP Ambetter PPO	844-463-8188	email
Ambetter HMO	888-926-2164	email
Health Net Employer Group HMO, POS, & PPO	800-641-7761	email
Medicare (Individual & Employer Group) (Wellcare By Health Net)	800-929-9224	email
Medicare Supplement	800-641-7761	email
Medi-Cal (including CS and ECM providers)	800-675-6110	N/A
Behavioral Health providers	844-966-0298	N/A

 

This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Behavioral Health Providers.

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.