Provider Alert! Annual Review of Clinical Prior Authorization Criteria Guides

Date: November 14, 2022

Attention: Providers

Effective date: November 29, 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’s Health Plan (TCHP) will revise the following clinical prior authorization criteria: Epidiolex, GLP-1 Receptor Agonists, Lovaza & Vascepa by November 29, 2022. The changes will be as follows:

• Epidiolex: TCHP will expand coverage of Epidiolex to treatment resistant seizures
• GLP-1 Receptor Agonists: TCHP will add medullary thyroid carcinoma (MTC) and multiple endocrine neoplasia syndrome type 2 (MEN 2) to the list of contraindications
• Lovaza & Vascepa: TCHP will expand coverage of Vascepa to members with elevated triglcyerides levels (TG> 150mg/dl) and Diabetes mellitus or established cardiovascular disease.

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)

 

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

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

 

3. 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)

 

4. 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)

 

Prior authorization criteria for GLP-1 Receptor Agonists will be the following:

1. Is the client greater than or equal to (≥) 18 years of age?

[ ] Yes (Go to #3)

[ ] No (And request is for Bydureon BCise or Victoza, go to #2)

[ ] No (And request is for any agent other than Bydureon BCise or Victoza, deny)

2. Is the client greater than or equal to (≥) 10 years of age?

[ ] Yes (Go to #3)

[ ] No (Deny)

3. Does the client have a diagnosis of type 2 diabetes in the last 365 days?

[ ] Yes (Go to #4)

[ ] No (Deny)

4. Does the client have a history of an oral antidiabetic agent for 14 days in the last 365 days?

[ ] Yes (Go to #7)

[ ] No (Go to #5)

5. Does the client have a history of the requested medication for 14 days in the last 365 days?

[ ] Yes (Go to #7)

[ ] No (Go to #6)

6. Does the client have a history of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF) or chronic kidney disease (CKD) in the last 365 days?

[ ] Yes (Go to #7)

[ ] No (Deny)

7. Does the client have a history of ESRD, pancreatitis, gastroparesis, medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2) in the last 730 days?

[ ] Yes (Deny)

[ ] No (Go to #8)

8. Does the client have a history of ESRD services (CPT codes) in the last 730 days?

[ ] Yes (Deny)

[ ] No (Go to #9)

9. Does the client have a history of an HbA1c test in the last 180 days?

[ ] Yes (Go to #10)

[ ] No (Deny)

10. Will the client have concurrent therapy with a GLP-1 RA containing agent?

[ ] Yes (Deny)

[ ] No (Approve – 365 days)

Prior authorization criteria for Lovaza & Vascepa will be the following:

1. Is the client greater than or equal to (³) 18 years of age?

[ ] Yes (Go to #2)

[ ] No (Deny)

2. Does the client have a diagnosis of severe hypertriglyceridemia (TG ≥ 500mg/dL) in the last 365 days?

[ ] Yes (Go to #3)

[ ] No (And the request is for Vascepa, go to #4)

[ ] No (Deny)

3. Has the patient failed a 30-day treatment trial with a fibrate in the last 180 days?

[ ] Yes (Go to #6)

[ ] No (Deny)

4. Does the client have a diagnosis of elevated triglyceride levels (TG ≥ 150mg/dL) AND diabetes mellitus or established cardiovascular disease?

[ ] Yes (Go to #5)

[ ] No (Deny)

5. Is the client currently on maximally tolerated statin therapy, or does the client have an intolerance or contraindication to statin therapy?

[ ] Yes (Go to #6)

[ ] No (Deny)

6. Is the quantity requested less than or equal to (£) 4 units per day?

[ ] Yes (Approve – 365 days)

[ ] No (Deny)

 

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

 

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers