Provider Alert! Prior Authorization Criteria to Change for Omalizumab (Xolair) Effective March 1, 2022Texas Children's Health Plan
Date: March 3, 2022
Attention: Primary care providers
Effective Date: March 01, 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: Effective on March 1, 2022, prior authorization criteria will change for omalizumab (Xolair) procedure code J2357. Prior authorization requests for clients with chronic idiopathic urticaria will no longer require documented failure of or contraindication to leukotriene inhibitor therapy.
How this impacts providers: Prior authorization for omalizumab (Xolair) will be considered for the following:
- Moderate to severe asthma
- For clients who are 6 years of age or older
- For clients who have a diagnosis of moderate to severe asthma (diagnosis codes J4540 and J4550)
- Chronic idiopathic urticaria (CIU)
- For clients who are 12 years of age or older
- For clients who have a diagnosis of CIU with symptoms despite H1 antihistamine treatment (diagnosis code L501)
- With documentation supporting medical necessity for the treatment of CIU with omalizumab submitted with the authorization request that includes the following:
- Documented failure of or contraindication to antihistamine
- Evidence of an evaluation that excludes other medical diagnoses associated with chronic urticaria
- Add-on maintenance treatment of nasal polyps
- For clients who are 18 years of age or older
- For clients who have a diagnosis of nasal polyps (diagnosis codes J330, J331, J338, and J339) with inadequate response to nasal corticosteroids
- With documentation supporting medical necessity for maintenance treatment of nasal polyps with omalizumab submitted with the authorization request that includes the following:
- Diagnosis of bilateral nasal polyposis confirmed by physical examination or nasal endoscopy
- Documented failure of or contraindication to prior corticosteroids as monotherapy
- Documented inadequate response to prior corticosteroid treatments
Documentation supporting medical necessity for the treatment of asthma with omalizumab must be submitted with the authorization request and include the following:
- Symptoms are inadequately controlled with the use of either combination therapy:
- 12 months of high-dose inhaled corticosteroid (ICS) given in combination with a minimum of 3 months of controller medication (either a long-acting beta2-agonist [LABA], leukotriene receptor antagonist [LTRA], or theophylline) unless the client is intolerant of or has a medical contraindication to these agents
- 6 months of ICS with daily oral glucocorticoids given in combination with a minimum of 3 months of controller medication (a LABA, LTRA, or theophylline) unless the client is intolerant of or has a medical contraindication to these agents
Next steps for providers: Prescribers should communicate these changes with their staff.
If you have any questions, please email Provider Network Management at: email@example.com.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
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