Provider Alert! Clinical Prior Authorization Updates for Cytokine and CAM Antagonist Agents

Provider Alert!

Provider Alert! Clinical Prior Authorization Updates for Cytokine and CAM Antagonist Agents

Date: March 25, 2021

Attention: Gastroenterologists, Rheumatologists

Effective Date: May 4, 2021

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: Effective May 4, 2021, the Texas Health and Human Services Commission (HHSC) will update the cytokine and cell-adhesion molecule (CAM) antagonist agents prior authorization criteria to reflect recent FDA-approved administration changes. This impacts the following agents: Actemra (tocilizumab), Cimzia (certolizumab pegol), Humira (adalimumab), Ilaris (canakinumab), Kineret (anakinra), and Simponi Aria (golimumab).

Actemra IV infusion no longer available through retail pharmacy benefits

Actemra (tocilizumab 20 mg/mL) IV infusions will only be available through the medical benefit (procedure code J3262).  Actemra ACTPen (auto-injector subcutaneous solution) and Actemra prefilled syringe subcutaneous solution will continue to be available through the pharmacy benefit.

Clinical prior authorization updates for other Cytokine CAM antagonists:

Drug Changes effective May 4, 2021
Cimzia (certolizumab pegol) A 30-day treatment trial of conventional therapy (e.g. mesalamine, sulfasalazine, corticosteroids, immunosuppressants) for Crohn’s disease must be tried in the last 6 months
Humira (adalimumab) Updated age to > 5 years for Ulcerative Colitis
Ilaris (canakinumab) Diagnosis of active Still’s disease added to approval criteria
Kineret (anakinra) Diagnosis of deficiency of interleukin-1 receptor antagonist (DIRA) added to approval criteria
Simponi Aria (golimumab) Diagnoses of polyarticular juvenile idiopathic arthritis (PJIA) and psoriatic arthritis (PsA) added to approval criteria for members > 2 years

Next steps for providers:
Providers should share this communication with their staff. The updated prior authorization forms will be made available near the effective date on the Navitus website (see Resources link below).



If you have any questions, please email TCHP Pharmacy Department at:

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