Medicare AdvantagePrior AuthHigh impact
20-960 Learn What Services Will Now Require a Prior Authorization Request
Health Net·Prior Authorization
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net Medicare Advantage HMO is implementing significant prior authorization changes effective January 1, 2021, including new PA requirements for 10 specific injectable medications (effective immediately), biosimilars, certain surgeries, and DME, while reducing PA requirements for outpatient therapy visits 1-12 and home sleep studies.
Action Required
Immediately: Billing team must obtain prior authorization for 10 specific injectable medications (Durysta, Istodax, Jelmyto, Monoferric, Pemfexy, Sarclisa, Tepezza, Trodelvy, Vyepti, Zulresso) before administration. By January 1, 2021: Update billing system to require PA for biosimilars, chondrocyte implants, hysterectomy, sacral nerve neuromodulation, lymphedema pumps/supplies, and vagus nerve stimulators. Remove PA requirements for outpatient therapy visits 1-12 and home sleep studies. Use Health Net's online PA validation tool to verify specific DME and Part B medication codes. Claims will be denied without proper prior authorization.