Medical Benefit Updates – Medi-Cal
| Date: | October 13, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Therapeutics Committee |
| To: | Health Plan Facilities and Hospitals |
| Type: | Informational |
| Subject: | Medical Benefit Updates |
| Business: | Medicare Advantage D-SNP |
Effective December 21, 2026, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
- CODE J2405 – INJECTION, ONDANSETRON HCL, PER 1 MG, CODE J2469 – INJECTION, PALONOSETRON HCL, 25 MCG, CODE J2765 – INJECTION, METOCLOPRAMIDE HCL TO 10MG, CODE J0184 – INJECTION, AMISULPRIDE, 1 MG: No PA required for Medicare benefit.
- CODE J8502- INJECTION, APONVIE, 1 MG: No PA required for Medicare benefit. This code replaces code C9145 which was marked obsolete as of 4/1/26.
- CODE J9119 – INJECTION, CEMIPLIMAB-RWLC, 1 MG: Medical necessity criteria will be applied. PA required for Medicare benefit.
- CODE J9232 – INJECTION, DOCETAXEL (HOSPIRA), NOT THERAPEUTICALLY EQUIVALENT TO J9171, 1 MG: No PA required for Medicare benefit.
- CODE 96401 – Chemotherapy administration, subcutaneous or intramuscular CODE 96402 – Chemotherapy injection, hormonal antineoplastic
CODE 96409 – Chemotherapy administration, IV push
CODE 96411 – Additional chemotherapy IV push
CODE 96413 – Chemotherapy administration, IV infusion (initial hour)
CODE 96415 – Additional hour of chemotherapy infusion
CODE 96417 – Additional chemotherapy infusion (up to 1 hour)
CODE 96372 – Therapeutic/diagnostic injection, subcutaneous or intramuscular CODE 96374 – Therapeutic/diagnostic injection, IV push
CODE 96375 – Additional sequential IV push
CODE 96376 – Additional IV push (same drug)
CODE 96377 – Application of on-body injector (e.g., for Neulasta)
CODE 96365 – IV infusion therapy/prophylaxis /dx 1st to 1 hr
CODE 96366 – IV infusion therapy prophylaxis/dx ea hour
CODE 96367 – IV infusion ther proph addl sequential to 1 hr
CODE 96368 – IV nfs therapy prophylaxis/dx concurrent nfs:
No PA required for Medicare benefit.
You may contact our Customer Service Department with any questions or concerns. For Medicare (D-SNP) members: 8:00 a.m. to 8:00 p.m., seven days a week from October 1 through March 31, and Monday to Friday from April 1 through September 30, at 1-888-361-7526 (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
