MedicaidPrior AuthHigh impact
24-1133 2025 Prior Authorization Changes to Medical Benefit Medications
Health Net·CA · Oncology, Nephrology, Urology +2 more·Prior Authorization
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
CalViva Health has updated prior authorization requirements for medical benefit medications effective January 1, 2025. Several drugs no longer require PA (including BCG, Nuzyra, Sandostatin, Sensipar), some existing requirements changed (Darzalex products, biosimilar preferences), and ten new drugs now require prior authorization including gene therapies and biologics.
Action Required
By January 1, 2025: Billing team must update prior authorization protocols for all listed HCPCS codes. Remove PA requirements for BCG (J9030), Nuzyra (J0121), Sandostatin (J2354), and Sensipar (J0604). Add PA requirements for 10 new medications including Anktiva (J9999), Beqvez (J3590), and others. Update billing system to reflect preference changes for biosimilar drugs. Contact CalViva Health at 888-893-1569 for questions. Claims may be denied without proper prior authorization.