Prior Authorization Requirement Changes

Date: 10/24/18

California Health & Wellness Plan (CHWP) is implementing changes to the prior authorization requirements, as described in this update and outlined in the table on pages 2 and 3.

Onpattro^TM – FDA Newly Approved Medication

Onpattro™ (patisiran) lipid complex injection was approved by the U.S. Food and Drug Administration (FDA) on August 10, 2018, as a treatment of peripheral nerve disease (polyneuropathy) caused by hereditary transthyretin-mediated amyloidosis (hATTR) in adult patients. Onpattro is a new specialty and biopharmacy therapy medication that requires prior authorization immediately.

ACCESSING Current PRIOR AUTHORIZATION REQUIREMENTS

Prior authorization requirements are available on www.CAHealthWellness.com.

Providers participating through the Community Care Independent Practice Association (CCIPA) must contact CCIPA, follow CCIPA’s prior authorization process and use CCIPA’s forms.

Services	Comment
ADDITIONS, EFFECTIVE JANUARY 1, 2019
Ablative techniques for treating Barrett’s esophagus, and for treatment of primary and metastatic liver malignancies
Capsule endoscopy
Joint replacement
Lung volume reduction
Maze procedures
Orthognathic procedures (includes TMJ treatment)
Spinal surgery, including, but not limited to: laminotomy, discectomy, vertebroplasty, nucleoplasty, and X-stop
Total joint replacement
Ventriculectomy, cardiomyoplasty
Vestibuloplasty
Uvulopalatopharyngoplasty (UPPP) and laser assisted UPPP
Crysvita,^® Elaprase,^® Fasenra,^™ Mepsevii,^™ Vimizim^®	Specialty and bio-pharmaceutical therapy medications requiring authorization effective January 1, 2019
CHANGES, EFFECTIVE JANUARY 1, 2019
Reconstructive and cosmetic surgery, services and supplies including, but not limited to: Bone alteration or reshaping, such as osteoplasty Breast reduction and augmentation except when following a mastectomy (includes for gynecomastia or macromastia) Dermatology, such as chemical exfoliation and electrolysis, dermabrasions and chemical peels, laser treatment or skin injections and implants Excision, excessive skin and subcutaneous tissue (including lipectomy and panniculectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas Eye or brow procedures, such as blepharoplasty, brow ptosis or canthoplasty Muscle flap Nasal surgery, such as rhinoplasty or septoplasty Otoplasty Penile Implant Treatment of varicose veins

Services	Comment
CHANGES, EFFECTIVE JANUARY 1, 2019, CONTINUED
Ambulance - Non emergency air transportation	Formerly listed as Transportation – Non-Emergency (fixed wing air transport). Non-emergency fixed wing transportation now requires prior authorization
Community Based Adult Services (CBAS) Prior authorization is required for greater than 5 visits per week. CBAS services with 1-5 visits per week require notification only. Fax authorization and notifications to 1-866-581-0540	Formerly all CBAS services required prior authorization
Durable medical equipment (DME), including, but not limited to: Bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) Bone growth stimulator Custom-made items including orthotics Hospital beds and mattresses Items with a total Medi-Cal purchase price greater than $1,500 Oxygen Power wheelchairs or scooters, repairs and accessories Prosthetics Ventilators All DME for pediatric members requires prior authorization	Formerly listed as DME – including but not limited to: medical supplies, wound vacs, customized equipment, orthotics and prosthetics.
DELETIONS, EFFECTIVE JANUARY 1, 2019
Select specialty and bio-pharmaceutical therapy medications (Refer to table on page 4)	Specialty pharmacy prior authorization information is on the CHWP provider website under Pharmacy.

Prior authorization is no longer required for the following specialty and bio-pharmaceutical therapy medications.

CPT Code	Description	CPT Code	Description
J7312	Injection, dexameth, intravitreal implant, 0.1 mg	J2783	Injection, rasburicase, 0.5 mg
J7315	Mitomycin, ophthalmic, 0. 2 mg	J0895	Injection, deferoxamine mesylate, 500 mg
J9155	Injection, degarelix, 1 mg	J9190	Injection, fluorouracil, 500 mg
J2358	Injection, olanzapine long-acting, 1 mg	J9280	Injection, mitomycin, 5 mg
J2426	Injection, paliperidone palmitate extended release, 1 mg	J9171	Injection, docetaxel, 1 mg
J3240	Injection, thyrotropin, 0.9 mg provided in 1.1 mg vial	J9263	Injection, oxaliplatin, 0.5 mg
J1930	Injection, lanreotide, 1 mg	J9031	BCG per instillation
J0485	Injection, belatacept, 1 mg	J9070	Cyclophosphamide, 100 mg
J2212	Injection, methylnaltrexone, 0.1 mg	J9201	Injection, gemcitabine hydroclordie, 200 mg
J2504	Injection, pegademase bovine, 25 iu	J9395	Injection, fulvestrant, 25 mg
J0401	Injection, aripiprazole extended release, 1 mg	J9181	Injection, etoposide, 10 mg
J2794	Injection, risperidone long acting, 0.5 mg	J9033	Injection, bendamustine hydroclordie, Treanda^®, 1 mg
J7511	Lymphcyte globulin, rabbit, parenteral, 25mg	J9100	Injection, cytarabine, 100 mg
J1680	Human fibrinogen concentrate injection	J9175	Injection, Elliotts B^® Solution, 1 ml
J2860	Injection, siltuximab, 10 mg	J9110	Cytarabine hydrochloride, 500 mg injection
J1190	Injection, dexrazoxane hydrochloride, per 250 mg	J9360	Injection, vinblastine sulfate, 1 mg
J2562	Injection, plerixafor, 1 mg	J9040	Injection, bleomycin sulfate, 15 units
J1640	Injection, hemin, 1 mg	J9151	Injection, daunorubicin citrate lip, 10 mg
J9400	Injection, ziv-aflibercept, 1 mg