CommercialPrior AuthHigh impact
21-749 Prior Authorization! Find Out What's New or Changing
Health Net·CA · Cardiology, ENT (Ear, Nose & Throat), Endocrinology +1 more·Prior Authorization
Effective date
Jan 1, 2022
We identified it
Jun 20, 2026
Summary
Health Net is implementing significant prior authorization changes effective January 1, 2022, including new PA requirements for specific injectable medications, ENT services, cardiac procedures, and continuous glucose monitoring for commercial plans, while adding community supports and enhanced care management requirements for Medi-Cal.
Action Required
By January 1, 2022: Billing team must update prior authorization workflows for new injectable medications (Aduhelm, Amondys 45, Danyelza, Margenzia, Pepaxto, Cosela, Jemperli, Rybrevant, Zynlonta) and outpatient pharmaceuticals (Abecma, Empaveli, Fensolvi, Nexviazyme, Sotradecol). For commercial EPO/PPO plans, add PA requirements for ENT services, cardiac procedures, and continuous glucose monitoring. Update billing system to route ENT and cardiac procedures to TurningPoint Healthcare Solutions for authorization. For Medi-Cal, add PA requirements for community supports, enhanced care management, and major organ transplants. Claims without proper prior authorization will be denied.