Medical Benefit Update – Effective June 9, 2025
| Date: | April 01, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Pharmacy and Therapeutics Committee |
| To: | Health Plan Providers and Physicians |
| Type: | Formulary |
| Subject: | Medical Benefit Update – Effective June 9, 2025 |
| Business: | Medi-Cal Managed Care |
Effective June 9, 2025, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- Code J3241 – INJECTION, TEPROTUMUMAB-TRBW (TEPEZZA), 10 MG: PA required. Reserved for all of the following:
- Either A or B
A) Moderate-to-severe active thyroid eye disease with a Clinical Activity Score >3 with either
1. Failure of a 4-week trial of a systemic corticosteroid (at up to maximally indicated doses), unless clinically significant adverse effects are experienced,
or all are contraindicated OR
2. Significant proptosis and/or diplopia.
B) Inactive thyroid eye disease with Clinical Activity Score <3 or no additional inflammation or progression in proptosis/diplopia for ≥1 year with
1. Proptosis ≥3 mm from before thyroid eye disease and/or from normal.
- Euthyroid or mild state (free thyroxine and triiodothyronine levels <50% +/− normal
limits) hypothyroidism or hyperthyroidism AND
- Patient must not have had optic nerve involvement within the last six months
Limited to up to 10 mg/kg for the first IV infusion, followed by 20 mg/kg IV every 3 weeks for 7 additional infusions. Must be prescribed by an endocrinologist/ophthalmologist. Patient must not have planned surgical ophthalmological intervention or radiation during Tepezza use. Patients with pre-diabetes/diabetes must be currently managed by an endocrinologist.
- Code J1071 – INJECTION, TESTOSTERONE CYPIONATE (DEPO-TESTOSTERONE), 1 MG; Code J3145 – INJECTION, TESTOSTERONE UNDECANOATE (AVEED), 1 MG: No PA required.
- Code S0189 – TESTOSTERONE PELLET (TESTOPEL), 75 MG: No PA required. Limited to a maximum of 450 mg (6 HCPCs units) every 90 days.
- Code J1830 – INJECTION INTERFERON BETA-1B (BETASERON), 0.25 MG; Code J1826 – INJECTION, INTERFERON BETA-1A (AVONEX), 30 MCG; Code Q3028 – INJECTION, INTERFERON BETA-1A (REBIF), 1 MCG FOR SUBCUTANEOUS USE; Code J1595 – INJECTION, GLATIRAMER ACETATE (GLATOPA), 20 MG: Prior Authorization required unless used for Multiple Sclerosis and the provider is in network.
- Code J9293 – INJECTION, MITOXANTRONE HCL, PER 5 MG (NOVANTRONE): PA required. Reserved as third line therapy for multiple sclerosis (MS) behind [1] Betaseron / Avonex / Rebif / Glatopa, AND [2] Gilenya, Aubagio, Tecfidera, or Vumerity due to increased risk of developing progressive multifocal leukoencephalopathy (PML). Documentation of a negative anti-JCV antibody test is required at initiation and annually for continuation. Prescription must be written by a neurologist.
- Code J0202 – INJECTION, ALEMTUZUMAB (LEMTRADA), 1 MG: PA required. Reserved for patients with relapsing remitting multiple sclerosis (RRMS) with inadequate treatment response to one drug from the following two categories: [1] Betaseron / Avonex / Rebif / Glatopa, AND [2] Gilenya, Aubagio, Tecfidera, or Vumerity. Members must have no previous history of malignancy, and documentation of negative HIV, HBV, HCV, and TB tests. Prescription must be written by a neurologist.
- Code J2350 – INJECTION, OCRELIZUMAB (OCREVUS), 1 MG; Code J3590 – HYALURONIDASE-OCSQ (OCREVUS ZUNOVO): PA required.
For patients with Relapsing MS (RMS): Reserved for patients who meet all of the following criteria:
A) Patient must either:
1. Have had an inadequate treatment response to one drug from each of the following two categories: [i] Betaseron / Avonex / Rebif / Glatopa, AND [ii] Gilenya, Aubagio, Tecfidera, or Vumerity; OR
2. Require high efficacy therapy due to meeting one of the following criteria:
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- EDSS score of ≥ 4 at 5 years of onset of the disease
- EDSS score ≥ 6 by 40 years of age or Multiple relapses (two or more) in the previous year or One relapse in the previous year with poor prognosis due to incomplete remission and/or followed by disability
- A minimum of 2 brain magnetic resonance imaging (MRI) studies with new lesions or increase in the size of the lesions in T2, or lesions that enhance with gadolinium despite adherence to MS treatment for at least 6 months
- ≥ 2 gadolinium-enhancing lesions on T1-weighted sequences or ≥ 9 lesions on T2-weighted sequences
- MRI lesions in the infratentorial region or spinal cord
- Multiple factors indicating poor prognosis (such as biomarkers, demographic factors, clinical factors, and/or radiological factors)
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B) Prescribed by a neurologist.
C) Lab documentation of a quantitative serum immunoglobulin test and a negative Hepatitis B Virus (HBV), at initiation.
For patients with Primary Progressive Multiple Sclerosis (PPMS): members must have documentation of a quantitative serum immunoglobulin test and negative HBV test at initiation. Prescription must be written by a neurologist, and patient must have chart notes showing a diagnosis of PPMS.
- Code J2329 – INJECTION, UBLITUXIMAB-XIIY (BRIUMVI), 1MG: PA required.
For patients with Relapsing MS (RMS): Reserved for patients who meet all of the following criteria:
A) Patient must either:
1. Have had an inadequate treatment response to one drug from each of the following two categories: [i] Betaseron / Avonex / Rebif / Glatopa, AND [ii] Gilenya, Aubagio, Tecfidera, or Vumerity; OR
2. Require high efficacy therapy due to meeting one of the following criteria:
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-
-
- EDSS score of ≥ 4 at 5 years of onset of the disease
- EDSS score ≥ 6 by 40 years of age or Multiple relapses (two or more) in the previous year
- One relapse in the previous year with poor prognosis due to incomplete remission and/or followed by disability
- A minimum of 2 brain magnetic resonance imaging (MRI) studies with new lesions or increase in the size of the lesions in T2, or lesions that enhance with gadolinium despite adherence to MS treatment for at least 6 months
- ≥ 2 gadolinium-enhancing lesions on T1-weighted sequences or ≥ 9 lesions on T2-weighted sequences o MRI lesions in the infratentorial region or spinal cord
- Multiple factors indicating poor prognosis (such as biomarkers, demographic factors, clinical factors, and/or radiological factors)
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B) Prescribed by a neurologist.
C) Lab documentation of a quantitative serum immunoglobulin test and a negative Hepatitis B Virus (HBV), at initiation.
- Code J2323 – INJECTION, NATALIZUMAB (TYSABRI), 1 MG; Code Q5134 – INJECTION, NATALIZUMAB-SZTN (TYRUKO), BIOSIMILAR, 1 MG: PA required. Reserved as third line therapy for MS behind [1] Betaseron / Avonex / Rebif / Glatopa, AND [2] Gilenya, Aubagio, Tecfidera, or Vumerity due to increased risk of developing progressive multifocal leukoencephalopathy (PML). Documentation of a negative anti-JCV antibody test is required at initiation and annually for continuation. Prescription must be written by a neurologist.
- Code P9046 – INFUSION, ALBUMIN (HUMAN), 25%, 20 ML; Code P9047 – INFUSION, ALBUMIN (HUMAN), 25%, 50 ML: No PA required.
For P9046: Limited to 25 units per date of service.
For P9047: Limited to 20 units per date of service.
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
