Medical Benefit Updates
| Date: | September 30, 2024 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan) |
| To: | Health Plan Practitioners and Facilities |
| Type: | Formulary |
| Subject: | Medical Benefit Updates |
| Business: | Medi-Cal Managed Care |
Effective December 9, 2024 the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- Code J3490 – INJECTION, SULBACTAM/DURLOBACTAM, (XACDURO): Prior authorization (PA) required. Medical necessity criteria as described in Health Plan Medical Review Guidelines (UM06) will be used for review.
- Code J0911 – INSTILLATION, TAUROLIDINE 1.35 MG AND HEPARIN SODIUM 100 UNITS, (DEFENCATH): No prior authorization required.
- Code J0585 – INJECTION, ONABOTULINUMTOXINA, (BOTOX), 1 UNIT: PA required. Must be 18 years or older. Must be prescribed by Neurologist. Limited to 1 injection (up to 200 units) per 3 months (12 weeks). Must meet ALL of the following criteria:
(1) ≥ 15 or more days per month for ≥ 3 months
(2) ≥ 4 hours a day or longer duration, as indicated by 5 or more attacks with ALL the following:
(a) Headache symptoms, as indicated by 2 or more of the following: *Aggravation by or causing avoidance of routine physical activity, or *Moderate or severe pain intensity, or *Pulsating quality, or *Unilateral location
(b) Migraine-associated symptoms, as indicated by 1 or more of the following: *Nausea or vomiting, or *Photophobia and phonophobia
(c) Other potential causes of headaches have been excluded
(3) No neuromuscular disease (e.g., myasthenia gravis).
- Code J0517 – INJECTION, BENRALIZUMAB, (FASENRA), 1MG: PA required. Reserved for patients ages 6 and older, with poorly controlled, severe eosinophilic asthma with baseline serum eosinophil counts of either ≥ 150 cells/µL at initiation of treatment or ≥ 300 cells/µL in the past 12 months AND 2 or more exacerbations in the past 12 months, despite being compliant with dose-optimized [1] High-dose Inhaled Corticosteroids (ICS) + [2] A second controller (e.g. Long-Acting Beta-2 Agonist (LABA), Long-Acting Muscarinic Antagonist (LAMA), leukotriene modifier, systemic corticosteroids). Must be prescribed by an allergist. Fasenra must not be used as monotherapy.
- Code J0665 – INJECTION, BUPIVICAINE NOS, 0.5 MG: No prior authorization required.
- Code J1010 – INJECTION, METHYLPREDNISOLONE ACETATE, 1 MG: No prior authorization required.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj-mvhp.org/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
