Provider Alert! Clinical Prior Authorization Criteria Revisions Implement for Medicaid Fee-for-Service on October 26

Date: October 5, 2022

Attention: All Providers

Subject: Effective Date: October 26, 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: Texas Children Health Plan (TCHP) will revise the clinical prior authorization criteria for the Anxiolytics and Sedative/Hypnotics (ASH), Attention Deficit Disorder/Attention-Deficit Hyperactivity Disorder (ADD/ADHD), and Qelbree (also within the ADD/ADHD Medications document) prior authorizations based on recent U.S. Food and Drug Administration (FDA) approved indications.

How this impacts providers: Effective October 26, 2022, the following revisions will be implemented:

• Anxiolytics and Sedative/Hypnotics prior authorization criteria
  • ICD-10 code: F13.90 “Sedative, Hypnotic, or Anxiolytic Use, Unspecified, Uncomplicated” is no longer considered a diagnosis of drug abuse
• ADD/ADHD clinical prior authorization criteria
  • New drugs were added to the clinical prior authorization criteria: Amphetamine extended release (ER) 1.25 mg/mL suspension, Methylphenidate extended release (ER) capsules and Methylphenidate long acting (LA)
  • Age check for Qelbree has been expanded to 6 years and older
  • For patients greater than or equal to 18 years prescribed non stimulants agents, a diagnosis of ADD/ADHD is no longer required.

Next steps for providers: Updated PA forms can be found on Navitus. Prescribers should share this communication 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.