Provider Alert! Clinical Prior Authorization Updates for Cytokine and CAM Antagonist Agents
Date: March 25, 2021
Attention: Gastroenterologists, Rheumatologists
Effective Date: May 4, 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: Effective May 4, 2021, the Texas Health and Human Services Commission (HHSC) will update the cytokine and cell-adhesion molecule (CAM) antagonist agents prior authorization criteria to reflect recent FDA-approved administration changes. This impacts the following agents: Actemra (tocilizumab), Cimzia (certolizumab pegol), Humira (adalimumab), Ilaris (canakinumab), Kineret (anakinra), and Simponi Aria (golimumab).
Actemra IV infusion no longer available through retail pharmacy benefits
Actemra (tocilizumab 20 mg/mL) IV infusions will only be available through the medical benefit (procedure code J3262). Actemra ACTPen (auto-injector subcutaneous solution) and Actemra prefilled syringe subcutaneous solution will continue to be available through the pharmacy benefit.
Clinical prior authorization updates for other Cytokine CAM antagonists:
| Drug | Changes effective May 4, 2021 |
| Cimzia (certolizumab pegol) | A 30-day treatment trial of conventional therapy (e.g. mesalamine, sulfasalazine, corticosteroids, immunosuppressants) for Crohn’s disease must be tried in the last 6 months |
| Humira (adalimumab) | Updated age to > 5 years for Ulcerative Colitis |
| Ilaris (canakinumab) | Diagnosis of active Still’s disease added to approval criteria |
| Kineret (anakinra) | Diagnosis of deficiency of interleukin-1 receptor antagonist (DIRA) added to approval criteria |
| Simponi Aria (golimumab) | Diagnoses of polyarticular juvenile idiopathic arthritis (PJIA) and psoriatic arthritis (PsA) added to approval criteria for members > 2 years |
Next steps for providers: Providers should share this communication with their staff. The updated prior authorization forms will be made available near the effective date on the Navitus website (see Resources link below).
Resources:
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.
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