Date: September 20, 2022 Attention: All ProvidersEffective Date: December 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with 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 December 1, 2022, the Health and Human Services Commission (HHSC) will update prior authorization criteria for Adakveo (procedure code J0791). HHSC updated the prior authorization criteria for Adakveo (Crizanlizumab-tmca). The following statement has been removed from the clinical policy and initial prior authorization request:
The client will not receive Adakveo (Crizanlizumab-tmca) therapy concomitantly with voxelotor (Oxbryta)
The following statement has been removed from the clinical policy and renewal/continuation authorization requirements
The client will not receive Adakveo (Crizanlizumab-tmca) therapy concomitantly with Oxbryta (Voxelotor)
How this impacts providers: Prior authorization approval Adakveo (Crizanlizumab-tmca) treatment in clients with sickle cell disease will be considered once all the following criteria are met:
Initial Requests
Initial therapy for Adakveo (crizanlizumab-tmca) may be approved for a 12-month duration if all of thefollowing criteria are met:
Clientmust be 16 years of age or older
Clienthas a diagnosis of sickle cell disease of any genotype
Clienthas experienced two or more vaso-occlusive events in the past 12 months
Renewal or Continuation Therapy
For renewal or continuation therapy, the client must meet all of the following requirements:
Client continues to meet the following initial approval criteria:
Client must be 16 years of age or older
Client has a diagnosis of sickle cell disease of any genotype
Client experienced positive clinical response to therapy as demonstrated by reduced frequency of vaso-occlusive crisis
Client has previously received treatment with Adakveo (crizanlizumab-tmca) without complications