Provider Alerts

Effective December 21, 2026, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. CODE J8502- INJECTION, APONVIE, 1 MG: No PA required for Medi-Cal benefit. This code replaces code C9145 which was marked obsolete as of 4/1/26.
2. CODE J3404 – INJECTION, ZOPAPOGENE IMADENOVEC-DRBA (PAPZIMEOS): PA required for Medi-Cal benefit. Reserved for patients who meet ALL of the following criteria:
   1. Age 18 years or older
   2. Histologically confirmed diagnosis of recurrent respiratory papillomatosis (RRP)
   3. Documented HPV (Human papillomavirus) serotype 6 or 11
   4. Prior to the very first dose, a surgical debulking procedure must be performed to remove visible papillomas and establish minimal residual disease
   5. Presence of laryngotracheal papillomas
   6. Patient has received or is planning to receive HPV vaccination, as indicated
      • Limits: Maximum of 4 injections per treatment course. 1 course of treatment.
3. CODE J2361 – INJECTION, DEPEMOKIMAB-ULAA, 1 MG (EXDENSUR): PA required for Medi-Cal benefit. Reserved for patients ages 12 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] Medium to highdose Inhaled Corticosteroids (ICS) + [2] A second controller (e.g. LongActing Beta-2 Agonist (LABA), Long-Acting Muscarinic Antagonist (LAMA), leukotriene modifier, systemic corticosteroids). Must be prescribed by an allergist/pulmonologist. Exdensur must not be used as monotherapy. Must have tried and failed Nucala/Fasenra/Cinqair.
   • Limits: None
4. CODE J2182 – INJECTION, MEPOLIZUMAB, 1 MG, CODE J0517 – INJECTION, BENRALIZUMAB, 1 MG, CODE J2786 – INJECTION, RESLIZUMAB, 1 MG, CODE J2356 – INJECTION, TEZEPELUMAB-EKKO, 1 MG: Adjust criteria definition for requirements in severe asthma to include medium-to-high-dose inhaled Corticosteroids (ICS). PA required for Medi-Cal benefit.
   1. CODE J2182 – INJECTION, MEPOLIZUMAB, 1 MG (Nucala): PA required for Medi-Cal benefit.
      • 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] medium-to-highdose 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/pulmonologist. 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 doseoptimized triple therapy with [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.
      • Limits: None
   2. CODE J0517 – INJECTION, BENRALIZUMAB, 1 MG (FASENRA): PA required for Medi-Cal benefit. 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] medium-to-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/pulmonologist. Fasenra must not be used as monotherapy.
      • Limits: None
   3. CODE J2786 – INJECTION, RESLIZUMAB, 1 MG (CINQAIR): PA required for Medi-Cal benefit. Reserved for patients ages 18 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] medium-to-high-dose Inhaled Corticosteroids (ICS) + [2] A second controller (e.g. Long-Acting Beta-2 Agonist (LABA), LongActing Muscarinic Antagonist (LAMA), leukotriene modifier, systemic corticosteroids). Must be prescribed by an allergist/pulmonologist. Cinqair must not be used as monotherapy.
      • Limits: None
   4. CODE J2356 – INJECTION, TEZEPELUMAB-EKKO, 1 MG (TEZSPIRE): PA required for Medi-Cal benefit. Reserved for patients ages 12 and older, with severe asthma AND 2 or more exacerbations in the past 12 months, despite being compliant with dose-optimized [1] medium-to-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/pulmonologist. Tezspire must not be used as monotherapy. Must not be used with anti-IgE, anti-IL4, or anti-IL5 monoclonal antibody agents.
      • Limits: None
5. CODE Q5168 – INJECTION, RANIBIZUMAB-LEYK, BIOSIMILAR, 0.1 MG (NUFYMCO), CODE J3490/J3590/C9399 – RANIBIZUMAB-HKDZ (RANLUSPEC): PA required for Medi-Cal benefit.
   • Must meet ALL of the following:
     • Eye condition appropriate for treatment, including:
       • Diabetic macular edema ▪ Diabetic retinopathy
       • Macular edema following retinal vein occlusion
       • Myopic choroidal neovascularization
       • Neovascular wet or exudative age-related macular degeneration
       • Polypoid choroidal vasculopathy with active juxtafoveal or subfoveal lesions
       • Indication approved by FDA or society guidelines
     • No concurrent ocular or periocular infection
     • Age 18 years or older
     • AND must have failed or had clinically significant adverse effects to bevacizumab
     • Limits: Limit one dose per eye every four weeks for ranibizumab injection and every 24 weeks (6 months) for Susvimo implant.
6. CODE J0178 – INJECTION, AFLIBERCEPT, 1 MG (EYLEA), CODE Q5147 – INJECTION, AFLIBERCEPT-AYYH (PAVBLU), BIOSIMILAR, 1 MG: Update to clarify bypass exceptions and to separate from Eylea HD. PA required for Medi-Cal benefit.
   • Must meet ALL of the following:
     • Eye condition appropriate for treatment, including:
       • Diabetic macular edema, with or without diabetic retinopathy
       • Macular edema following central or branch vein occlusion
       • Neovascular (wet or exudative) age-related macular degeneration
       • Indication approved by FDA or society guidelines
     • No concurrent ocular or periocular infection
     • Age 18 years or older
     • AND must have failed or had clinically significant adverse effects to bevacizumab OR patient’s baseline visual acuity is 20/50 or worse with diabetic macular edema.
     • Limits: Limit to standard dosing of one 2 mg dose per eye every 4 weeks.
7. CODE J0177 – INJECTION, AFLIBERCEPT HD, 1 MG (EYLEA HD): Update to criteria requiring trial of ranibizumab or aflibercept. PA required for Medi-Cal benefit.
   • Must meet ALL of the following:
     • Eye condition appropriate for treatment, including:
       • Diabetic macular edema, with or without diabetic retinopathy
       • Macular edema following central or branch vein occlusion
       • Neovascular (wet or exudative) age-related macular degeneration
       • Indication approved by FDA or society guidelines
     • No concurrent ocular or periocular infection
     • Age 18 years or older
     • AND must have failed or had clinically significant adverse effects to ranibizumab or aflibercept.
   • Limits:
     • Limit to standard dosing of one 8 mg dose every 4 weeks for the first three (3) doses, followed by 8 mg once every 8 to 16 weeks (±1 week).
       • Eylea HD maintenance dosing for every 4 weeks may only be approved for patients who have (1) documented initial response to the first 3-5 monthly doses and (2) documented loss of response following maintenance dosing of every 8 to 16 weeks.
8. CODE J2777 – INJECTION, FARICIMAB-SVOA, 0.1 MG (VABYSMO): Update to criteria requiring trial of ranibizumab or aflibercept. PA required for Medi-Cal benefit.
   • Must meet ALL of the following:
     • Eye condition appropriate for treatment, including
       • Neovascular (wet or exudative) age-related macular degeneration
       • Diabetic macular edema, with or without diabetic retinopathy
       • Indication approved by FDA or society guidelines
     • No concurrent ocular or periocular infection
     • Age 18 years or older
     • AND must have failed or had clinically significant adverse effects to ranibizumab or aflibercept
     • Limits: Does not exceed standard dosing per FDA package insert.
9. CODE J0179 – INJECTION, BROLUCIZUMAB-DBLL, 1 MG (BEOVU): Update to criteria requiring ranibizumab or aflibercept. PA required for Medi-Cal benefit.
   • Must meet ALL of the following:
     • Eye condition appropriate for treatment, including
       • Neovascular (wet or exudative) age-related macular degeneration
       • Diabetic macular edema, with or without diabetic retinopathy
       • Indication approved by FDA or society guidelines
     • No concurrent ocular or periocular infection
     • Age 18 years or older
     • AND must have failed or had clinically significant adverse effects to ranibizumab or aflibercept
     • Limits: Does not exceed standard dosing per FDA package insert.
10. CODE J9119 – INJECTION, CEMIPLIMAB-RWLC, 1 MG: Medical necessity criteria will be applied. PA required for Medi-Cal benefit.
11. CODE J9232 – INJECTION, DOCETAXEL (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J9171, 1 MG: No PA required for Medi-Cal benefit. You may contact our Customer Service Department with any questions or concerns. For Medi-Cal only members: Monday through Friday, 8:00 am to 5:00 pm, at 1-888-936-7526 (PLAN), TDD/TTY 711.

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