Tag - clinical criteria

19Oct

Provider Alert! Clinical Criteria for Qalsody® (procedure code C9157) effective October 1, 2023

Date: October 19, 2023 Attention: All Providers Effective Date: October 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective October 1, 2023, Texas Health and Human Services Commission (HHSC) will be implementing prior authorization criteria for Qalsody® (procedure code C9157).Qalsody® (Tofersen) is an antisense oligonucleotide indicated for the treatment of amyotrophic lateral sclerosis (ALS) in adults who have a mutation in the superoxide dismutase 1 (SOD1) gene Prior Authorization Requirements: Criteria for Initial Approval: Patient is 18...

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Provider Alert!
27Sep

Provider Alert! Clinical Criteria for Leqembi® (procedure code J0174) effective November 1, 2023

Date: September 26, 2023 Attention: Physicians Effective date for prior authorization criteria: November 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective November 1 2023, the Texas Health and Human Services (HHSC) will be implementing prior authorization criteria for Leqembi® (procedure code J0174) for fee-for-service Medicaid. Leqembi (Lecanemab-irmb) is an amyloid-beta directed antibody indicated for early stages of Alzheimer’s disease. Prior Authorization Requirements: Criteria for Initial Approval: Patient has Alzheimer’s disease (Diagnosis codes: G30.0, G30.1, G30.8 or...

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Provider Alert!
27Sep

Provider Alert! Clinical Criteria for Hemgenix® (procedure code J1411) effective November 1, 2023

Date: September 26, 2023 Attention: Physicians Effective date for prior authorization criteria: November 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective November 1 2023, the Texas Health and Human Services (HHSC) will be implementing prior authorization criteria for Hemgenix® (procedure code J1411) for fee-for-service Medicaid. Hemgenix (etranacogene dezaparvovec-drlb) is an adeno-associated virus vector-based gene therapy indicated to treat adult patients with Hemophilia B (congenital Factor IX deficiency). Prior Authorization Requirements: Coverage will be provided for...

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Provider Alert!
13Jul

Provider Alert! Clinical Criteria for Tzield® (procedure code J9381) effective August 1, 2023

Date: July 11, 2023 Attention: All Providers Effective Date: August 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective August 1, 2023, the Texas Health and Human Services (HHSC) will be implementing prior authorization criteria for Tzield ® (procedure code J9381). The approval duration will be for the 14-day treatment. Tzield is the first-in-class therapy indicated to delay the onset of Stage 3 Type 1 diabetes (T1D) in adults and pediatric patients 8 years...

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Provider Alert!
24May

Provider Alert! Clinical Criteria Revision for Evkeeza® effective June 1, 2023

Date: May 18, 2023 Attention: All Providers Effective Date: June 1, 2023 Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective June 1, 2023, Texas Health and Human Services (HHSC) will expand coverage for Evkeeza® (procedure code J1305) to adolescents 5 years of age and older due to a recent U.S. Food and Drug Administration (FDA) approval. Evkeeza® is an injectable prescription medicine used along with other low-density lipoprotein (LDL) lowering medicines in treating high cholesterol...

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Provider Alert!
26Oct

Provider Alert! Clinical Criteria Update for Orkambi Effective November 9

Date: October 25, 2022 Attention: Providers Effective Date: October 1, 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 clinical prior authorization criteria for Orkambi (lumacaftor/ivacaftor) to comply with the recent Food and Drug Administration-approved age indications. How this impacts...

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