Provider Alert! Clinical Prior Authorization Updates for Epidiolex
Date: March 26, 2021
Attention: Neurologists
Effective Date: May 11, 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 11, 2021, the Texas Health and Human Services Commission (HHSC) will update the ICD-10 diagnosis codes for Epidiolex (cannabidiol) for consistency with diagnosis codes used for Diacomit (stiripentol). These drugs are FDA-approved to treat Dravet Syndrome. The following ICD-10 codes will be added to the Epidiolex prior authorization criteria:
| ICD-10 Code | Description (Effective May 11, 2021) |
| G40411 | Other generalized epilepsy and epileptic syndromes, intractable with status epilepticus |
| G40419 | Other generalized epilepsy and epileptic syndromes, intractable without status epilepticus |
| G40803 | Other epilepsy, intractable, with status epilepticus |
| G40804 | Other epilepsy, intractable, without status epilepticus |
Next steps for providers: Providers should share this communication with their staff. The updated Epidiolex prior authorization form will be made available near the effective date on the Navitus website (see Resources link below).
Resources:
If you have any questions, please email TCHP Pharmacy Department at: tchppharmacy@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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