Provider Alert! Prior Authorization Changes for Fasenra and NucalaTexas Children's Health Plan
Date: February 19, 2021
Attention: Allergists & Immunologists, Pulmonologists
Effective Date: April 6, 2021
Call to action: Texas Children’s Health Plan (TCHP) is modifying prior authorization criteria for two monoclonal antibodies available through the pharmacy benefit: Fasenra (benralizumab) and Nucala (mepolizumab).
Both are monoclonal antibodies approved for the treatment of severe asthma. The Texas Health and Human Services Commission (HHSC) revised the clinical prior authorization criteria for these agents to enhance appropriate utilization per the US Food and Drug Administration’s (FDA) approved indications and dosing.
How this impacts providers: On April 6, 2021, HHSC will make the following changes to the prior authorization criteria for Monoclonal Antibody Agents:
- Criterion will be extended to allow the member to receive the first maintenance dose (the fourth dose) up to 180 days from the treatment initiation date.
- Dosing criteria will be updated to clarify maximum allowed per day for approval
- > 1 syringe or pen per 56 days is 0.018 units per day
- > 1 syringe or pen per 28 days is 0.036 units per day
- Nucala vials that require reconstitution will not be covered under the pharmacy retail benefit. This formulation cannot be self-administered, and must be administer by a healthcare professional.
- Nucala 100 mg vials for reconstitution (NDC 00173-0881-01) will continue to be available through the medical benefit as a clinician administered drug only.
- Nucala pre-filled auto-injector (NDC 00173-0892-01) and pre-filled syringe (NDC 00173-0892-42) will continue to be available through the retail pharmacy benefit and medical benefit.
Next steps for providers: Providers should communicate these changes to their staff. New PA forms can be obtained from the Navitus website once it is available.
Providers also should ensure their members are not self-administering Nucala vials and receiving the drug from a healthcare professional. Providers should also ensure Nucala vials are not being processed through the retail pharmacy.
Resource: Navitus TX Medicaid Prior Authorization forms
If you have any questions, please email TCHP Pharmacy Department at: TCHPPharmacy@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.