Provider Alert! Updates to Prior Authorization Requirements for CADs, electronic bone growth stimulators, home telemonitoring, and hospital beds

Attention: All providers

Effective Date: February 1, 2021

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) would like to inform network providers of Prior Authorization updates.

Clinician Administered Drugs (CAD) that require a prior authorization effective February 1, 2021:

• 90378, Synagis- for all members, available through the pharmacy benefit
• J1746    Injection, ibalizumab-uiyk, 10 mg (Trogarzo)
• J3397    Injection, vestronidase alfa-vjbk, 1 mg (Mepsevii)
• J9269    Injection, tagraxofusp-erzs, 10 mcg (Elzonris)
• J0129    Injection, abatacept, 10 mg (Orencia)
• J0220    Injection, alglucosidase alfa, 10 mg, not otherwise specified
• J0221    Injection, alglucosidase alfa, (Lumizyme), 10 mg
• J0517    Injection, benralizumab, 1 mg   (Fasenra)
• J9027    Injection, clofarabine, 1 mg (Clolar)
• J7311    Injection, fluocinolone acetonide, intravitreal implant (Retisert), 0.01 mg
• J2357    Injection, omalizumab, 5 mg  (Xolair)
• J2786    Injection, reslizumab, 1 mg  (Cinqair)

Electronic Bone Growth Stimulators that require a prior authorization effective February 1, 2021:

• E0749 Osteogenesis stimulator, electrical, surgically implanted
• E0760 Osteogenesis stimulator, low intensity ultrasound, noninvasive

How this impacts providers: Providers should follow the new prior authorization guidelines and submit the requests for coverage timely to ensure payment. The turnaround time for routine requests is three business days.

Next steps for providers: Providers should inform their staff of the new prior authorization requirements.

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.