Medical Benefits Updates
| Date: | October 03, 2023 |
| To: | Health Plan of San Joaquin (HPSJ) Physicians and Providers |
| Type: | Formulary |
| Subject: | Medical Benefits Updates |
| Business: | Medi-Cal Managed Care |
Effective December 11, 2023, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.
1. Code J2327 – INJECTION, RISANKIZUMAB-RZAA, (SKYRIZI), 1 MG: For Acute and Chronic Bowel Disease: PA required. Reserved for treatment failure to Corticosteroids, Thiopurines, Methotrexate, and TNF inhibitors AND must have tried and failed Stelara. Requires fill history or documentation of treatment failure to Corticosteroids, Thiopurines, Methotrexate, TNF inhibitors, and Stelara. Must be prescribed by Gastroenterologist.
2. Code Q5121 – INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR (AVSOLA), 10 MG: For Acute and Chronic Bowel Disease: PA required. Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids. Must be prescribed by a Gastroenterologist.
3. Code J3032 – INJECTION, EPTINEZUMAB-JJMR (VYEPTI), 1 MG:
For Migraine: PA required. Reserved for patients who have failed 6 months of therapy with Botox, Atogepant (Qulipta), prophylactic-dosed Rimegepant (Nurtec), Erenumab (Aimovig), Fremanezumab (Ajovy), or Galcanezumab (Emgality) and are 18 years of age or older. Must be prescribed by a Neurologist. Limit to one infusion per 3 months and requires clinical documentation, chart notes, and pharmacy fill history indicating all the criteria listed above are met.
4. Code J9035 – INJECTION, BEVACIZUMAB (AVASTIN), 10 MG:
Limited to 2 units per date of service when J9035 is billed with procedure code 67028. Any requests beyond this limit or that is not associated with procedure code 67028 will require Prior Authorization.
You may contact our Customer Service Department with any questions or concerns, Monday through Friday, 8:00 am to 5:00 pm, at 1-888-936-PLAN (7526), TDD/TYY 711. Thank you for your continued support of Health Plan of San Joaquin. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/. If you have questions, please contact the Provider Services team at 1.888.936.PLAN (7526).