Provider Alert! Adakveo Update

Attention: Hematologists
Effective Date: July 1, 2020

Call to action: Texas Children’s Health Plan (TCHP) aligns with the prior authorization criteria available in the most recent Texas Medicaid Provider Procedures Manual (TMPPM), Clinician Administered Drugs Handbook. Prior authorization guidelines began May 26, 2020. Adakveo, Injection, crizanlizumab – clinician administered drug HCPCS code C9053 is being replaced with Code J0791. This new Code, J0791 will follow the same prior authorization requirements. Adakveo (Crizanlizumab-tmca) is indicated for members with sickle cell disease to reduce the frequency of vaso-occlusive crises.

Adakveo must be prescribed by, or in consultation with, a hematologist or a sickle cell disease specialist.

 For initial therapy, the following criteria must be met:

• Age 16 or older
• Diagnosis of sickle cell disease of any genotype
• Experienced two or more vaso-occlusive events in the past 12 months

Have not received crizanlizumab-tmca (Adakveo) therapy concurrently with voxelotor (Oxbryta)

Continue to meet the initial approval criteria:

• Age 16 or older
• Diagnosis of sickle cell disease of any genotype
• Has not received crizanlizumab-tmca (Adakveo) therapy concurrently with  voxelotor (Oxbryta)

For renewal or continuation of therapy, the following criteria must be met:

• Continue to meet the initial approval criteriaAge 16 or older
• Diagnosis of sickle cell disease of any genotype
• Has not received crizanlizumab-tmca (Adakveo) therapy concurrently with voxelotor (Oxbryta)
• Experienced a positive clinical response to therapy as demonstrated by reduced frequency of vaso-  occlusive crisis
• Has previously received treatment with crizanlizumab-tmca (Adakveo) without complications

How this impacts providers: Prescribers should adjust their prescribing patterns accordingly and communicate these changes to their staff.

References: https://www.novartis.us/sites/www.novartis.us/files/adakveo.pdf

Next steps for providers: Providers should communicate these changes to their staff.

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