MedicaidPrior AuthHigh impact
20-853 Learn What Services Will Now Require a Prior Authorization Request
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net is implementing new prior authorization requirements for the Cal MediConnect Plan (Medicare-Medicaid Plan) effective January 1, 2021. Multiple new medications now require PA, including 10 injectable medications effective immediately, plus 26 additional outpatient pharmaceuticals. Changes also affect DME (CPAP/BiPap devices), occupational/speech therapy (PA required after 12 combined visits), and self-injectable medications.
Action Required
Immediately: Update billing system to require prior authorization for 10 injectable medications (Durysta, Istodax, Jelmyto, Monoferric, Pemfexy, Sarclisa, Tepezza, Trodelvy, Vyepti, Zulresso) and 26 outpatient pharmaceuticals listed in policy. By January 1, 2021: Modify authorization workflows for CPAP/BiPap devices, occupational/speech therapy after 12 visits, and updated self-injectable medication list. Access Health Net provider portal to verify current PA requirements before submitting claims. Claims submitted without required PA will be denied.