Medical Benefit Update – Effective December 15, 2025
| Date: | October 1, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Physicians, Providers & Facilities |
| Type: | Formulary |
| Subject: | Medical Benefit Update – Effective December 15, 2025 |
| Business: | Medi-Cal Managed Care |
Effective December 15, 2025, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
1. Code J7601 – Ensifentrine (Ohtuvayre), 3mg: PA required.
- Must be for an FDA-approved indication and dosage.
- Inadequate response, intolerance, or contraindication to a long-acting beta-2 agonist (LABA), long-acting muscarinic antagonist (LAMA), and inhaled corticosteroid (ICS) therapy.
- Inadequate response, intolerance, or contraindication to roflumilast.
2. Code J2182 – Injection, Mepolizumab (Nucala), 1 mg: PA required.
- For asthma: Nucala is 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. Nucala must not be used as monotherapy.
- For COPD: Nucala is reserved for adult patients with poorly controlled severe eosinophilic COPD 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 moderate exacerbations or 1 severe exacerbation in the past 12 months, despite being compliant with dose optimized [1] High-dose Inhaled Corticosteroids (ICS) + [2] A Long-Acting Beta-2 Agonist (LABA), and [3] Long-Acting Muscarinic Antagonist (LAMA). Must be prescribed by an allergist. Nucala must not be used as monotherapy.
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
