What to know about Rx and DHCS updates
Star Ratings help ensure the best benefits for members
As of Jan. 1, 2026, Alliance members eligible for both Medi-Cal and Medicare may be able to enroll in the Alliance’s TotalCare (HMO D-SNP) plan, which combines Medi-Cal and Medicare benefits into a single plan.
The Centers for Medicare & Medicaid Services (CMS) Star Ratings program is crucial to TotalCare’s success and revenue. Here’s what you need to know.
What are Star Ratings?
Star Ratings help Medicare beneficiaries compare the quality of Medicare health and drug plans in their service area.
Ratings range from 1 to 5 stars, with 5 stars indicating the highest quality. Scores are based on over 40 measures, using data from a variety of sources like HEDIS measures, member surveys and prescription drug and operational measures.
Why Star Ratings matter
CMS awards plans with 4 stars or more with bonus payments. These funds can be used to:
- Reduce costs for members.
- Help fund supplemental benefits not traditionally covered by Medicare.
How providers make an impact
Your engagement is essential to the plan’s Star Rating. Here’s how you can improve our Star Ratings:
- Document preventative services accurately and on time.
- Close care gaps through proactive scheduling and follow-up.
- Support medication adherence, including refill synchronization and counseling on side effects.
- Coordinate care transitions to reduce readmissions.
- Promote preventive care, including colorectal and breast cancer screenings and vaccines.
- Capture coding and data accurately to reflect the member’s health profile and support HEDIS and Star Ratings measures.
- Encourage member participation in health assessments, care plans and satisfaction surveys.
If you have any questions, please contact your Provider Services representative.
Physician administered drugs changes to know, effective Dec. 1, 2025
The Alliance has made changes to physician administered drug benefits. You can find prior authorization (PA) criteria on our website.
The changes are as follows:
| HCPCS Code | Drug | Change | Preferred Drug |
| GnRH Agonists | |||
| J9217 | Leuprolide acetate (Lupron Depot, Eligard 7.5mg) | No PA required | |
| J1950 | Leuprolide acetate (Lupron Depot 3.75mg) | Modified PA criteria. | Use HCPCS code J9217 for prostate cancer. |
| J3315 | Triptorelin (Trelstar) | Modified PA criteria. | |
| J9226 | Histrelin implant
(Supprelin LA) |
||
| J3316 | Triptorelin XR (Triptodur) | ||
| J9202 | Goserelin acetate (Zoladex) | New PA criteria. | |
| J1951 | Leuprolide acetate (Fensolvi) | ||
| J1954 | Leuprolide acetate (Lutrate 7.5mg) | ||
| J1952 | Leuprolide mesylate (Camcevi) | ||
| New Biosimilar HCPCS Codes | |||
| Q5098 | Ustekinumab-Srlf (Imuldosa) | New PA criteria.
|
Infliximab (Remicade, Inflectra, Renflexis, Avsola, Zymfentra)
|
| Q5099 | Ustekinumab-Stba (Steqeyma) | ||
| Q5100 | Ustekinumab-Kfce (Yesintek) | ||
| Q5153 | Aflibercept-Yszy (Opuviz) | New PA criteria. | Bevacizumab (Avastin) and ranibizumab (Lucentis) |
| Q5155 | Aflibercept-Jbvf (Yesafili) | ||
| Q5154 | Omalizumab-Igec (Omlyclo) | New PA criteria. | |
| Q5156 | Tocilizumab-Anoh (Avtozma) | New PA criteria. | DMARD (methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine) |
| Q5157 | Denosumab-Bmwo (Stoboclo/Osenvelt) | New PA criteria. | Zoledronic acid |
| Q5158 | Denosumab-Bnht (Bomyntra/Conexxence) | ||
| Q5136 | Denosumab-Bbdz (Jubbonti/Wyost) | ||
The Alliance has updated the following pharmacy policies.
- 403-1101 Pharmacy Operations Management.
- Attachment A Medi-Cal Rx MCP Portal Procedures.
- Attachment B Medi-Cal Rx Designated User Management.
- 403-1150 Pharmacist Service.
To request a copy, please call the Alliance Pharmacy Department at 831-430-5507.
Review the All Plan Letter (APL) updates
The Department of Health Care Services has updated DHCS APL 25-012.
These changes are important to know, as they may impact how you provide services.
For more information about this APL and others, you can visit our All Plan Letters webpage. You can also find related Alliance policies and procedures in the Alliance Provider Manual.
