MedicaidPrior AuthMedium impact
26-1202 Updates to Prior Authorization Requirements
Health Net·CA · Oncology, Rheumatology, Physical Therapy·Prior Authorization
Effective date
Oct 27, 2026
We identified it
Oct 27, 2026
Summary
Health Net updated prior authorization (PA) requirements for Medi-Cal LA-DHS effective immediately and January 1, 2027. Changes include: biosimilar medication preferred/non-preferred status shifts (effective now), new PA requirements for gene therapy (Kresladi™), pegfilgrastim (Ennumo™), Yondelis® (J9352), and scalp cooling (CPT 97007, 97008, 97009) starting January 1, 2027, and removal of PA requirements for discontinued Community Supports services on the same date.
Action Required
IMMEDIATE (effective 2026-10-27): Billing and clinical teams must update medication formulary status in practice systems for all biosimilar denosumab and ustekinumab agents listed, distinguishing preferred vs. non-preferred status by indication (bone metastasis vs. osteoporosis for denosumab). Verify member eligibility and benefits before prescribing or billing these medications. BY 2027-01-01: Prior authorization team must implement PA requirement triggers in billing software for CPT codes 97007, 97008, 97009 (scalp cooling) and HCPCS code J9352 (Yondelis®), and configure system to submit PA requests for new gene therapy (Kresladi™) and pegfilgrastim (Ennumo™) products. Remove PA requirement flags for Assisted Living Facility Transitions, Personal Care and Homemaker Services, and Short-Term Post-Hospitalization Housing in billing and authorization workflows. For any non-compliant claims submitted between the effective dates and implementation date, expect denial without prior authorization.