Provider Alert! Prior Authorization Criteria Update for Rinvoq and Cibinqo

Date: June 28, 2022

Attention: All Providers

Effective Date: August 31, 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) would like to inform providers that the Health and Human Services Commission (HHSC) updated the prior authorization criteria for Rinvoq and Cibinqo. They are cytokine and cell-adhesion molecule (CAM) antagonists, which are subjected to both clinical and preferred drug list (PDL) prior authorizations. The prior authorizations reflect recent U.S. Food and Drug Administration (FDA) approved indications and recommendations from Texas Drug Utilization Review Board.

How this impacts providers: Below are the updates to the clinical prior authorization criteria:

Rinvoq

• Updated systemic therapy list for treatment of atopic dermatitis to include oral immunomodulators and oral glucocorticoids.
• Added Rinvoq ER 30 mg Tablets (GCN 51719) and Rinvoq ER 45 mg Tablet (GCN 52085) and added coverage for the diagnosis of ankylosing spondylitis.
• Added clarification about prior therapy criteria for clients with atopic dermatitis. It should be 30 continuous days in the last 90 days, but for prior authorization renewal, 30-day prior therapy is not required.

Cibinqo

• Added clarification about prior therapy criteria for clients with atopic dermatitis. It should be 30 continuous days in the last 90 days, but for prior authorization renewal, 30-day prior therapy is not required.

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

Resources:

paxpress.txpa.hidinc.com/cytokinepend.pdf

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.