MedicaidPrior AuthMedium impact
26-1199 Updates to Prior Authorization Requirements
Health Net·CA · Oncology, Physical Therapy, Rheumatology +1 more·Prior Authorization
Effective date
Oct 27, 2026
We identified it
Oct 27, 2026
Summary
Health Net/CalViva Health updated prior authorization (PA) requirements for select medications and services across three effective dates: biosimilar preferred/non-preferred status changes are effective immediately (2026-10-27), while new PA requirements for gene therapy, pegfilgrastim, Yondelis®, and scalp cooling procedures take effect January 1, 2027, and Community Supports services discontinue PA requirements on the same date.
Action Required
IMMEDIATE (effective 2026-10-27): Billing team must update medication formulary status in billing system for denosumab and ustekinumab biosimilars, reflecting changes to preferred and non-preferred designations to avoid claim denials based on incorrect authorization status. BY JANUARY 1, 2027: Billing team must implement prior authorization requirements for CPT codes 97007, 97008, 97009 (scalp cooling) and HCPCS code J9352 (Yondelis®), and activate PA requirement flags for gene therapy (Kresladi™) and pegfilgrastim (Ennumo™) in billing software. Simultaneously, remove PA requirements for discontinued Community Supports services (Assisted Living Facility Transitions, Personal Care and Homemaker Services, Short-Term Post-Hospitalization Housing). Front-desk staff and providers must verify member eligibility before providing services requiring new PA. Incomplete or incorrect PA submissions may result in member appeals and grievances; refer to Provider Library resources on Prior Authorization Requirements and Appeals/Grievances.