19-670 Prior Authorization Requirements Changes
Date: 08/27/19
Changes for Zolgensma® medication and other requirements
Zolgensma – FDA newly approved medication
The U.S. Food and Drug Administration (FDA) approved Zolgensma on May 24, 2019. Effective immediately, Zolgensma requires prior authorization (PA). Zolgensma is used to treat pediatric patients under age two with spinal muscular atrophy (SMA) with bi-allelic mutations in the survival motor neuron 1 (SMN1) gene.
See California Health and Wellness Plan’s (CHWP) provider website “Pre-Auth Check” page to verify prior authorization status of provider administered drugs at www.cahealthwellness.com/providers/resources/prior-authorization.html.
Prior authorization changes
As a reminder, all services for members under age 21* and select durable medical equipment (DME) require prior authorization. Effective November 1, 2019, CHWP is updating the online Pre-Auth Check tool to be in line with these requirements. Be sure to check the tool to confirm authorization requirements before providing services. If a provider fails to obtain prior authorization before providing these services, the claim may be denied.
Additions to the prior authorization requirements, effective November 1, 2019:
- Avastin® (for non-Ophthalmologist only)
- Kyprolis®
- Perjeta®
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
If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.
*Prior authorization is not required for well visits, preventive services, immunizations, emergency services, urgent care services, minor consent services (sexual assault, pregnancy care, family planning, sexually transmitted disease services), HIV testing, abortion.
CHWP follows the Department of Health Care Services (DHCS) Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics regarding authorization requirements.