Provider Alert! Implementation of Hormonal Therapy Agents Clinical Prior Authorization

Provider Alert!

Provider Alert! Implementation of Hormonal Therapy Agents Clinical Prior Authorization

Date: May 28, 2024
Attention: All Providers

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that on May 17, 2024 Health and Human Services Commission (HHSC) published an updated Hormonal Therapy Agents Clinical prior authorization criteria guide that was originally implemented on March 1, 2024.

Previous TCHP provider alerts on hormonal therapy agents:

Clinical Implementation of Hormonal Therapy Agents Clinical Prior Authorization Effective March 1, 2024: https://www.thecheckup.org/2024/02/02/provider-alert-clinical-implementation-of-hormonal-therapy-agents-clinical-prior-authorization-effective-march-1-2024/

Clinical Criteria Implementation for Enzyme Replacement Hormonal Therapy Agents effective May 1, 2024: https://www.thecheckup.org/2024/04/18/provider-alert-clinical-criteria-implementation-for-enzyme-replacement-hormonal-therapy-agents-effective-may-1-2024/

How this impacts providers: May 17, 2024 updates include the following.

  • Adding GCNs for:
    • Methitest (10411)
    • Oxandrolone (10561, 18265)
    • Synarel (84354)
    • Testosterone Cypionate (10194, 10191)
    • Lyllana (28840, 28841, 28842, 28843, 28846)
    • Alora (28840, 28841, 28842, 28843)
    • Minivelle (28840, 28841, 28842, 28843, 28846)

  • Correcting GCN for:
    • Kyzatrex from 52948 to 52648

  • Removing GCN for:
    • Lupron Depot-Ped 45 mg 6mo kit (54034)

Next step for Providers: Providers are strongly encouraged to follow the guidance as specified above. Prescribers should share this communication with their staff. Providers must stay up-to-date on the latest restrictions and indications for these agents to ensure appropriate use and maximize patient outcomes. Provider must submit documentation (such as office chart notes, lab results, other pertinent clinical information, etc.) supporting that the member has met all appropriate criteria for medication approval.

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.

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