Provider Alert! Clinical Prior Authorization Criteria Revisions for Bylvay Scheduled for Nov. 21Texas Children's Health Plan
Date: November 2, 2022
Effective Date: November 21, 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) will revise clinical prior authorization criteria for Bylvay. The new prior authorization (PA) criteria will be effective November 21, 2022. TCHP will change question 2 on the PA criteria from “Does the client have a diagnosis of progressive familial intrahepatic cholestasis (PFIC) confirmed with genetic testing? [Manual]” to “Does the client have a diagnosis of PFIC type 2 with ABCB11 variants resulting in the non-functional or complete absence of bile salt export pump protein (BSEP-3)?”
How this impacts providers: Effective November 21, 2022, the prior authorization criteria will be as follows:
- Is this a renewal request?
Yes (Go to #6) No (Go to #2)
- Does the client have a diagnosis of PFIC type 2 with ABCB11 variants resulting in the non-functional or complete absence of bile salt export pump protein?
Yes (Go to #3) No (Deny)
- Does the client have a history of a liver transplant?
Yes (Deny) No (Go to #4)
- Does the client have a history of biliary diversion surgery in the last 180 days?
Yes (Deny) No (Go to #5)
- Has the client had at least 90 days therapy in the last 180 days of a standard agent used for the treatment of cholestasis pruritis?
Examples of standard agents include cholestyramine (QUESTRAN, QUESTRAN LIGHT, PREVALITE), naltrexone, rifampin, sertraline (ZOLOFT), ursodiol (URSO, URSO FORTE)
Yes (Go to #6) No (Deny)
- Does the client have an alanine aminotransferase (ALT) and total bilirubin that is less than (<) 10 times the upper limit of normal (ULN)?
Yes (Go to #7) No (Deny)
- Is the request for less than or equal to (≤) 5 capsules per day?
Yes (Approve-365 days) No (Deny)
Next steps for providers: Updated PA forms will be found on Navitus page. Prescribers should share this communication with their staff.
If you have any questions, please email Provider Network Management at: firstname.lastname@example.org.