Provider Alert! Clinical Criteria Revision for Hereditary Angioedema Agents (HAE) effective June 1,2023
Date: June 9, 2023
Attention: All Providers
Effective Date: June 1, 2023
Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective June 1, 2023, the Texas Health and Human Services (HHSC) added age and diagnosis restriction for HAE agents. Please see the drugs impacted below:
| Drug | Procedure Code | Age | Diagnosis |
| Berinert® | J0597 | ≥ 5 years | D84.1 |
| Kalbitor® | J1290 | ≥ 12 years | D84.1 |
| Firazyr® | J1744 | ≥ 18 years | D84.1 |
| Takhzyro® | J0593 | ≥ 2 years | D84.1 |
How this impacts providers: Starting June 1 2023, TCHP will have diagnosis and age restrictions for HAE agents including Berinert®, Kalbitor®, Firazyr® and Takhzyro®. Providers will have to adhere to the age and diagnosis restriction in order to get reimbursed.
Next steps for providers: Prescribers should share this communication with their staff. Providers must stay up-to-date on the latest restrictions and indications for these agents to ensure appropriate use and maximize patient outcomes. Provider must submit documentation (such as office chart notes, lab results, other pertinent clinical information, etc.) supporting that the member has met all appropriate criteria for medication approval. Updated prior authorization (PA) forms can be found on Navitus. Since these drugs also qualify for the medical benefit, please 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.
Note: If request is for a dose or indication that is not approved by the U.S. Food and Drug Administration (FDA), medical rational must be submitted in support of therapy (such as high-quality peer reviewed literature, acceptable compendia or evidence based practice guidelines) and exceptions will be considered on a case-by-case basis.
If you have any questions, please email TCHP Pharmacy at: tchppharmacy@texaschildrens.org.
For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers
