Provider Alert! Clinical Implementation of Hormonal Therapy Agents Clinical Prior Authorization Effective March 1, 2024

Date: February 1, 2024

Attention: All Providers

Effective Date: March 1, 2024

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective March 1, 2024, the Texas Health and Human Services (HHSC) will implement clinical prior authorizations to hormonal therapy agents.

HHSC will implement criteria for the following procedure codes:

• J1000   (depo-estradiol cypionate, up to 5mg)
• J1071   (inj testosterone cypionate, 1 mg)
• J1380   (inj estradoiol valerate, up to 10 mg)
• J1950   (inj leuprolide acetate, per 3.75 mg)
• J1951   (inj leuprolide acetate, fensolvi, 0.25 mg)
• J3121   (inj testosterone enanthate, 1 mg)
• J3145   (inj testosterone undecanoate, 1mg)
• J3315   (inj triptorelin pamoate, 3.75 mg)
• J3316   (inj triptorelin ER, 3.75 mg)
• J9155   (inj degarelix, 1mg (Firmagon))
• J9217   (depo leuprolide acetate, 7.5mg)
• J9218   (depo leuprolide acetate, per 1mg)
• J9226   (histrelin implant, 50mg (Supprelin LA))
• S0189   (testosterone pellet, 75 mg (Testropel))

Prior authorization criteria: claims will not pay when billed with the following ICD 10 codes:

• F64.0   (gender dysphoria of adolescence or adulthood)
• F64.1   (dual role transvestism)
• F64.2   (gender identity disorder of childhood)
• F64.8   (other gender identity disorders)
• F64.9   (gender identity disorder, unspecified)

How this impacts providers: Providers will have to adhere to the clinical prior authorization criteria.

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.