Provider Alert! Epidiolex Clinical Prior Authorization Criteria Update

Provider Alert!

Provider Alert! Epidiolex Clinical Prior Authorization Criteria Update

Date: June 21, 2022

Attention: All Providers

Effective Date: August 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.

TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.

Providers should direct questions to their Provider Relations Liaison or send an email inquiry to the Provider Relations Department at providerrelations@texaschildrens.org.

Call to action: Texas Children’s Health Plan (TCHP) has updated the clinical prior authorization for Epidiolex to include patients with a diagnosis of uncontrolled, intractable, refractory, treatment-resistant, or drug-resistant epilepsy

How this impacts providers: Prior authorization criteria for Epidiolex will be the following:

  1. Does the client have paid claims for greater than or equal to (≥) 60 days of cannabidiol (Epidiolex) in the last 90 days?

[] Yes (Approve – 365 days)
[] No (Go to #2)

  1. Is the client greater than or equal to (≥) 1 year of age?

[] Yes (Go to #3)
[] No (Deny)

  1. Does the client have a diagnosis of Lennox-Gastaut syndrome, Dravet syndrome or tuberous sclerosis complex in the last 730 days?

[] Yes (Approve – 365 days)
[] No (Go to #4)

  1. Does the client have a diagnosis of uncontrolled, intractable, refractory, treatment-resistant, or drug-resistant epilepsy? [MANUAL STEP]

[] Yes (Go to #5)
[] No (Deny)

  1. Does the client have a history of paid claims for at least 2 other anticonvulsant agents (other than cannabidiol, Epidiolex), each for greater than or equal to (≥) 30 days in the last 365 days?

[] Yes (Approve – 365 days)
[] No (Deny)

Next steps for providers: Prescribers can find updated prior authorization for Epidiolex on the Navitus page. Prescribers should share this update with their staff.

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.

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