Medical Benefit Update – Effective March 9, 2026
| Date: | December 16, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Physicians & Providers |
| Type: | Formulary |
| Subject: | Medical Benefit Update – Effective March 9, 2026 |
| Business: | Medi-Cal Managed Care |
Effective March 9, 2026, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- Code J3402 – INJECTION, REMESTEMCEL-L-RKND, (RYONCIL): Prior authorization (PA) required. Reserved for patients with all of the following:
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- Steroid-refractory acute graft versus host disease (SR-aGvHD)
- For pediatric patients 2 months to ≤ 17 years of age
- Progression of aGVHD within 3 days of ≥ 2 mg/kg/day methylprednisolone or equivalent therapy OR no clinical improvement within 7 consecutive days of ≥ 2 mg/kg/day methylprednisolone or equivalent therapy
- Limits: NONE
- Required Information for Approval: Documentation that previous steroid treatment(s) was tried and had inadequate response, intolerance, or contraindication.
- Notes: N/A
- Code J9038 – INJECTION, AXATILIMAB-CSFR, 0.1 MG, (NIKTIMVO): Prior authorization (PA) required. Reserved for patients with all of the following:
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- Chronic graft-versus-host disease (cGVHD).
- Previous failure of at least two prior lines of systemic therapy.
- Adult and pediatric patients weighing at least 40 kg.
- No concurrent JAK inhibitors and BTK inhibitors will be used with Niktimvo.
- No known active relapse of the underlying hematologic malignancy.
- Limits: NONE.
- Required Information for Approval: Documentation that other appropriate therapies (including steroids, calcineurin inhibitors, JAK inhibitors, BTK inhibitors, etc.) were tried and had inadequate response, intolerance, or contradiction. Documented history of allogeneic hematopoietic stem cell transplantation (HSCT).
- Notes: Patients may have acute GVHD (graft-versus-host disease) if there is overlapping cGVHD.
- Code J3489 (injection, zoledronic acid, 1 mg); P9046 (infusion, albumin (human), 25%, 20mL); P9047 (infusion, albumin (human), 25%, 25mL): No restrictions.
- Code 67028 (intravitreal injection of a pharmacologic agent into the eye): Limited to 2 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
