Provider Alert! Prior Authorization Criteria for Aduhelmtcph
Date: December 28, 2021
Attention: All Providers
Effective Date: January 1, 2022
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: HHSC will add the drug Aduhelm (procedure code J0172) as of Jan. 1, 2022 and implement these criteria for fee-for-service Medicaid on Feb. 1, 2022.
Key Details: Aduhelm (Aducanumab-avwa) is an amyloid-beta directed antibody indicated to treat Alzheimer’s disease (AD) by reducing amyloid-beta plaques. Treatment with ADUHELM should be initiated in patients with mild cognitive impairment or mild dementia stage of disease.
Initial prior authorization approval of Aduhelm (Aducanumab-avwa) J0172 infusion therapy will be considered when the following criteria are met:
- The client has a confirmed diagnosis of Alzheimer’s disease (G30.0, G30.1 G30.8 G30.9).
- The prescriber attestation of other forms of dementia except Alzheimer’s disease were ruled out by appropriate lab or another diagnostic testing.
- The prescriber’s confirmation of amyloid beta-plaques presence
- Clinical testing must confirm client has mild cognitive impairment caused by Alzheimer’s disease or mild stage of Alzheimer’s disease
- The client must currently not be taking any anti-coagulant (except for aspirin at a prophylactic dose or less) or have a history of a clotting disorder.
- Documentation the client has received a baseline brain-magnetic resonance imaging (MRI) before initiating treatment (within the past year).
Monitoring requirements during the treatment period:
- The prescriber must monitor for amyloid-related imaging abnormalities (ARIA) during the first eight treatment doses, particularly during titration.
- Prescriber attestation to obtain an MRI prior to the 7th and 12th infusion to check for ARIA.
- Clients with severe amyloid-related imaging abnormalities hemosiderin deposition (ARIA-H) may continue therapy only if radiographic stabilization has been confirmed by a follow-up MRI and supported by clinical evaluation.
For renewal or continuation therapy client must meet the following requirements:
- The client continues to meet the initial authorization approval criteria.
- The client has not progressed to moderate or severe dementia caused by AD.
- The client experienced positive clinical response to therapy as demonstrated by no increase in amyloid plaque or radiographic stabilization as compared to baseline.
- Documentation of MRI before the 7th and 12th infusion to check for ARIA.
- The client has not experienced any complications or unacceptable toxicities during Aduhelm treatment.
Refer to the Outpatient Drug Services Handbook Chapter of the TMPPM for more details on the clinical policy and prior authorization requirements.