Provider Alerts

Effective on or after November 30, 2022, DHCS and HPSJ will no longer reimburse Bebtelovimab as the FDA has announced that the agent is no longer authorized for emergency use anywhere in the US as it is not expected to neutralize Omicron subvariants BQ.1 and BQ.1.1.

Effective March 20, 2023, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code J0739 INJECTION CABOTEGRAVIR (APRETUDE) 1 MG
   1. Bill directly to Medi-Cal FFS.
2. Code Q0166 GRANISETRON HCL (KYTRIL, SANCUSO) 1 MG, ORAL
   Code J0185 INJECTION, APREPITANT (EMEND), 1 MG
   Code J1454 INJECTION, FOSNETUPITANT 235 MG AND PALONOSETRON 0.25 MG (AKYNZEO)
   Code J8655 NETUPITANT 300 MG AND PALONOSETRON 0.5 MG, ORAL (AKYNZEO)
   1. For use with chemotherapy regimens, no Prior Authorization (PA) is required.
   2. For any other indications, PA is required.
3. Code J1439 – INJECTION, FERRIC CARBOXYMALTOSE (INJECTAFER), 1 MG
   1. PA required. Reserved for patients with one or more of the following AND have documented history of treatment failure or inability to tolerate Venofer or Feraheme:
   2. Absolute iron deficiency anemia with a ferritin < 30μg/L or TSAT < 20% with treatment failure or inability to tolerate oral iron.
   3. Chronic kidney disease with or without dialysis with ferritin < 500μg/L and TSAT < 30% with treatment failure or inability to tolerate oral iron for non-dialysis patients.
   4. Chemotherapy-induced anemia with ferritin 30-500μg/L or TSAT < 50% in patients receiving ESAs. Ferritin must not exceed 800μg/L, and TSAT must not be ≥ 50%.
4. Code J0885 – INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS
   Code Q4081 – INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS)
   Code Q5105 – INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR ESRD ON DIALYSIS), 100 UNITS
   Code Q5106 – INJECTION, EPOETIN ALFA-EPBX, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS (RETACRIT, EPOGEN, PROCRIT)
   1. PA required. Retacrit, Epogen, or Procrit are reserved for patients who have Hemoglobin (Hgb) < 10 g/dl, with TSAT > 20% or serum ferritin > 100 ng/ml at initiation.
5. Code J0881 – INJECTION, DARBEPOETIN ALFA, 1 MCG (NON-ESRD USE)
   Code J0882 – INJECTION, DARBEPOETIN ALFA, 1 MCG (FOR ESRD ON DIALYSIS) (ARANESP)
   Code J0887 – INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR ESRD ON DIALYSIS)
   Code J0888 – INJECTION, EPOETIN BETA, 1 MICROGRAM, (FOR NON-ESRD USE) (MIRCERA)
   1. PA required. Reserved for patients who have Hemoglobin (Hgb) < 10 g/dl, with TSAT > 20% or serum ferritin > 100 ng/ml at initiation.

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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.