Provider Alert! Age Limitation Change for Antisense Oligonucleotides BenefitsTexas Children's Health Plan
Effective Date: For dates of service on or after January 1, 2020
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Texas Children’s Health Plan (TCHP) aligns with the prior authorization criteria available in the most recent Texas Medicaid Provider Procedures Manual, Clinician Administered Drugs Handbook. Effective for date dates of service on or after January 1, 2020, antisense oligonucleotides eteplirsen (Exondys 51) code J1428 and Nusinersen (Spinraza) code J2326 benefits changed for Texas Medicaid.
Procedure codes J1428 and J2326 will no longer have age limitations, and prior authorization requests will be considered for clients of any age.
How this impacts providers: Claims with dates of service on or after January 1, 2020 that were denied for client age, will be reprocessed and may result in an additional payment, which will be reflected on future Remittance and Status (R&S) Reports.
Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.