Provider Alert! Prior Authorization Criteria Update for Adakveo

Date: September 20, 2022

Attention: All Providers

Effective Date: December 1, 2022

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with 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 December 1, 2022, the Health and Human Services Commission (HHSC) will update prior authorization criteria for Adakveo (procedure code J0791). HHSC updated the prior authorization criteria for Adakveo (Crizanlizumab-tmca). The following statement has been removed from the clinical policy and initial prior authorization request:

• The client will not receive Adakveo (Crizanlizumab-tmca) therapy concomitantly with voxelotor (Oxbryta)

The following statement has been removed from the clinical policy and renewal/continuation authorization requirements

• The client will not receive Adakveo (Crizanlizumab-tmca) therapy concomitantly with Oxbryta (Voxelotor)

How this impacts providers: Prior authorization approval Adakveo (Crizanlizumab-tmca) treatment in clients with sickle cell disease will be considered once all the following criteria are met:

Initial Requests

• Initial therapy for Adakveo (crizanlizumab-tmca) may be approved for a 12-month duration if all of thefollowing criteria are met:
  • Clientmust be 16 years of age or older
  • Clienthas a diagnosis of sickle cell disease of any genotype
  • Clienthas experienced two or more vaso-occlusive events in the past 12 months

Renewal or Continuation Therapy

• For renewal or continuation therapy, the client must meet all of the following requirements:
  • Client continues to meet the following initial approval criteria:
    • Client must be 16 years of age or older
    • Client has a diagnosis of sickle cell disease of any genotype
  • Client experienced positive clinical response to therapy as demonstrated by reduced frequency of vaso-occlusive crisis
  • Client has previously received treatment with Adakveo (crizanlizumab-tmca) without complications

Next steps for providers: Refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual for more details on the clinical policy and prior authorization requirements.

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

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