CommercialPrior AuthHigh impact
24-1134 2025 Prior Authorization Changes to Medical Benefit Medications
Health Net·CA · Oncology, Nephrology, Urology +5 more·Prior Authorization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Health Net California is updating prior authorization requirements for medical benefit medications effective January 1, 2025. Several drugs no longer require PA (BCG, Nuzyra, Sandostatin, Sensipar), while multiple new drugs now require PA including oncology and specialty medications. Some existing drugs have changed from preferred to non-preferred status.
Action Required
By January 1, 2025: Billing team must update prior authorization requirements in billing system - remove PA for codes J9030, J0121, J2354, J0604 and add PA for codes J9999, J3590, J1300, J9325, J3490, J2820, J3262, Q5124, Q5121. Update encounter forms and notify providers that Ziextenzo (Q5120) changed to non-preferred status requiring different authorization. Claims submitted without proper PA will be denied.