MedicaidPrior AuthMedium impact
24-1136 2025 Prior Authorization Changes to Medical Benefit Medication
Health Net·CA · Oncology, Hematology, Nephrology +2 more·Prior Authorization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Community Health Plan of Imperial Valley updated prior authorization requirements for medical benefit medications effective January 1, 2025. Ten new drugs now require prior auth (including cancer therapies and biologics), two existing requirements changed preferred status, and four drugs no longer need prior authorization.
Action Required
By January 1, 2025: Billing team must update prior authorization requirements in billing system for 15 HCPCS/J-codes. Add prior auth requirements for 10 new medications (Anktiva, BeqvezTM, BkemvTM, etc.), update preferred status for Darzalex codes, and remove prior auth requirements for 4 medications (BCG Intravesical, Nuzyra, Sandostatin, SensiparTM). Update encounter forms and notify providers. Claims without proper authorization will be denied.