Provider Alert! Prior Authorization Criteria for Aduhelm

Provider Alert!

Provider Alert! Prior Authorization Criteria for Aduhelm

Date: December 28, 2021

Attention: All Providers

Effective Date: January 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: HHSC will add the drug Aduhelm (procedure code J0172) as of Jan. 1, 2022 and implement these criteria for fee-for-service Medicaid on Feb. 1, 2022.

Key Details: Aduhelm (Aducanumab-avwa) is an amyloid-beta directed antibody indicated to treat Alzheimer’s disease (AD) by reducing amyloid-beta plaques. Treatment with ADUHELM should be initiated in patients with mild cognitive impairment or mild dementia stage of disease.

Additional Information:

Initial prior authorization approval of Aduhelm (Aducanumab-avwa) J0172 infusion therapy will be considered when the following criteria are met:

  • The client has a confirmed diagnosis of Alzheimer’s disease (G30.0, G30.1 G30.8 G30.9).
  • The prescriber attestation of other forms of dementia except Alzheimer’s disease were ruled out by appropriate lab or another diagnostic testing.
  • The prescriber’s confirmation of amyloid beta-plaques presence
  • Clinical testing must confirm client has mild cognitive impairment caused by Alzheimer’s disease or mild stage of Alzheimer’s disease
  • The client must currently not be taking any anti-coagulant (except for aspirin at a prophylactic dose or less) or have a history of a clotting disorder.
  • Documentation the client has received a baseline brain-magnetic resonance imaging (MRI) before initiating treatment (within the past year).

Monitoring requirements during the treatment period:

  • The prescriber must monitor for amyloid-related imaging abnormalities (ARIA) during the first eight treatment doses, particularly during titration.
  • Prescriber attestation to obtain an MRI prior to the 7th and 12th infusion to check for ARIA.
  • Clients with severe amyloid-related imaging abnormalities hemosiderin deposition (ARIA-H) may continue therapy only if radiographic stabilization has been confirmed by a follow-up MRI and supported by clinical evaluation.

For renewal or continuation therapy client must meet the following requirements:

  • The client continues to meet the initial authorization approval criteria.
  • The client has not progressed to moderate or severe dementia caused by AD.
  • The client experienced positive clinical response to therapy as demonstrated by no increase in amyloid plaque or radiographic stabilization as compared to baseline.
  • Documentation of MRI before the 7th and 12th infusion to check for ARIA.
  • The client has not experienced any complications or unacceptable toxicities during Aduhelm treatment.

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Refer to the Outpatient Drug Services Handbook Chapter of the TMPPM for more details on the clinical policy and prior authorization requirements.

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