Medical Benefit Update- Effective 06/01/2026
| Date: | March 11, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Pharmacy and Providers |
| To: | Health Plan Pharmacy and Therapeutics Committee |
| Type: | Formulary |
| Subject: | Medical Benefit Update- Effective 06/01/2026 |
| Business: | Medi-Cal Managed Care/Medicare D-SNP |
Effective 06/01/2026, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- Code J1938 – INJECTION, FUROSEMIDE (LASIX), 1MG – No PA required.
- Code J9202 – INJECTION, GOSERELIN ACETATE IMPLANT (ZOLADEX), 3.6MG – No PA required.
- Code J7042 – 5% DEXTROSE/NORMAL SALINE – No PA required.
- Code J9201 – INJECTION, GEMCITABINE HYDROCHLORIDE (GEMZAR), 200 MG – No PA required.
- Code J9035 – INJECTION, BEVACIZUMAB (AVASTIN), 10 MG – No PA required.
- Code J1930 – INJECTION, LANREOTIDE (SOMATULINE DEPOT), 1 MG – No PA 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.com/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
