Clinical Prior Authorization Updates for Cytokine and CAM Antagonist Agents

Date: March 25, 2021Attention: Gastroenterologists, RheumatologistsEffective Date: May 4, 2021Providers 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 May 4, 2021, the Texas Health and Human Services Commission (HHSC) will update the cytokine and cell-adhesion molecule (CAM) antagonist agents prior authorization criteria to reflect recent FDA-approved administration changes. This impacts the following agents: Actemra (tocilizumab), Cimzia (certolizumab pegol), Humira (adalimumab), Ilaris (canakinumab), Kineret (anakinra), and Simponi Aria (golimumab). Actemra IV infusion no longer available through retail pharmacy benefits Actemra (tocilizumab 20 mg/mL) IV infusions will only be available through the medical benefit (procedure code J3262).  Actemra ACTPen (auto-injector subcutaneous solution) and Actemra prefilled syringe subcutaneous solution will continue to be available through the pharmacy benefit. Clinical prior authorization updates for other Cytokine CAM antagonists:

Drug	Changes effective May 4, 2021
Cimzia (certolizumab pegol)	A 30-day treatment trial of conventional therapy (e.g. mesalamine, sulfasalazine, corticosteroids, immunosuppressants) for Crohn’s disease must be tried in the last 6 months
Humira (adalimumab)	Updated age to > 5 years for Ulcerative Colitis
Ilaris (canakinumab)	Diagnosis of active Still’s disease added to approval criteria
Kineret (anakinra)	Diagnosis of deficiency of interleukin-1 receptor antagonist (DIRA) added to approval criteria
Simponi Aria (golimumab)	Diagnoses of polyarticular juvenile idiopathic arthritis (PJIA) and psoriatic arthritis (PsA) added to approval criteria for members > 2 years

Next steps for providers: Providers should share this communication with their staff. The updated prior authorization forms will be made available near the effective date on the Navitus website (see Resources link below). Resources:

1. https://txstarchip.navitus.com/pages/prior-authorization-forms.aspx

If you have any questions, please email TCHP Pharmacy Department at: tchppharmacy@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.