Provider Alert! Prior Authorization Criteria Update for Aduhelm Begins July 1

Date: June 15, 2022

Attention: All Providers

Subject: Prior Authorization Criteria Update for Aduhelm Begins July 1

Effective Date: July 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: Texas Children’s Health Plan (TCHP) would like to inform providers that the Health and Human Services Commission (HHSC) will update prior authorization criteria for Aduhelm (J0172) in response to recent revisions to the FDA label, and a CMS National Coverage Determination published on April 7, 2022. HHSC will include this update in the July 2022 Texas Medicaid Provider Procedures Manual (TMPPM).

How this impacts providers: Recent evidence suggests that most asymptomatic amyloid-related imaging abnormalities (ARIA) occur during the titration phase of Aduhelm, thus enhanced clinical vigilance is recommended. Beginning July 1, 2022, HHSC will add the following criteria for initial requests:

• The prescriber attestation to obtain a brain magnetic resonance imaging (MRI) prior to the 5th, 7th, 9th, and 12th infusion to check for ARIA.

HHSC will update the following criteria for re-certification or extension:

• Documentation of a brain MRI prior to the 5th, 7th, 9th and 12th infusion to check for ARIA.

Next steps for providers: Providers should refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual for more details on the clinical policy and prior authorization requirements. Prescribers should also adjust their prescribing patterns accordingly and share this update with their staff.

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