Provider Alert! Cytokine and CAM Antagonists Criteria Updates Scheduled for April 5

Date: March 10, 2022

Attention: Providers

Effective Date: April 5th, 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: On April 5, 2022, HHSC will make the following revisions to various Cytokine and CAM Antagonists clinical prior authorization criteria to ensure alignment with US Food and Drug Administration approved indications.

How this impacts providers:

• Cosentyx 

• Add diagnosis of enthesitis-related arthritis for patients greater than or equal to 4 years.
• Add diagnosis of ankylosing spondylitis, remove a check for methotrexate/DMARDs, and add a check for prior therapy with a TNF-blocker.
• Enbrel
  • The age changed is to 2 years.
• Orencia 
  • Add diagnosis for prophylaxis of acute graft versus host disease in patients greater than or equal to 2 years in combination with a calcineurin inhibitor and methotrexate.
• Otezla 
  • Remove ‘moderate to severe’ from plaque psoriasis.
• Rinvoq 
  • Add diagnosis of psoriatic arthritis, remove a check for methotrexate, and add a check for prior therapy with a TNF-blocker.
  • Add diagnosis of atopic dermatitis and add a check for prior therapy with a systemic agent for atopic dermatitis.
• Skyrizi
  • Add diagnosis of psoriatic arthritis.
• Xeljanz
  • Update question 1 (Is the client greater or equal to 2 years?). A negative will result in a denial.

The updated prior authorization criteria can be found on Navitus.

Next steps for providers: Prescribers should adjust their prescribing patterns accordingly and share this update with their staff as well

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.