Date: November 14, 2022Attention: ProvidersEffective date: November 29, 2022Providers 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 the following clinical prior authorization criteria: Epidiolex, GLP-1 Receptor Agonists, Lovaza & Vascepa by November 29, 2022. The changes will be as follows:
- Epidiolex: TCHP will expand coverage of Epidiolex to treatment resistant seizures
- GLP-1 Receptor Agonists: TCHP will add medullary thyroid carcinoma (MTC) and multiple endocrine neoplasia syndrome type 2 (MEN 2) to the list of contraindications
- Lovaza & Vascepa: TCHP will expand coverage of Vascepa to members with elevated triglcyerides levels (TG> 150mg/dl) and Diabetes mellitus or established cardiovascular disease.
How this impacts providers:
Prior authorization criteria for
Epidiolex will be the following:
- Does the client have paid claims for greater than or equal to (≥) 60 days of cannabidiol (Epidiolex) in the last 90 days?
[] Yes (Approve – 365 days)
[] No (Go to #2)
- Is the client greater than or equal to (≥) 1 year of age?
[] Yes (Go to #3)
[] No (Deny)
- Does the client have a diagnosis of Lennox-Gastaut syndrome, Dravet syndrome or tuberous sclerosis complex in the last 730 days?
[] Yes (Approve – 365 days)
[] No (Go to #4)
- Does the client have a history of paid claims for at least 2 other anticonvulsant agents (other than cannabidiol, Epidiolex), each for greater than or equal to (≥) 30 days in the last 365 days?
[] Yes (Approve – 365 days)
[] No (Deny)
Prior authorization criteria for
GLP-1 Receptor Agonists will be the following:
- Is the client greater than or equal to (≥) 18 years of age?
[ ] Yes (Go to #3)
[ ] No (And request is for Bydureon BCise or Victoza, go to #2)
[ ] No (And request is for any agent other than Bydureon BCise or Victoza, deny)
- Is the client greater than or equal to (≥) 10 years of age?
[ ] Yes (Go to #3)
[ ] No (Deny)
- Does the client have a diagnosis of type 2 diabetes in the last 365 days?
[ ] Yes (Go to #4)
[ ] No (Deny)
- Does the client have a history of an oral antidiabetic agent for 14 days in the last 365 days?
[ ] Yes (Go to #7)
[ ] No (Go to #5)
- Does the client have a history of the requested medication for 14 days in the last 365 days?
[ ] Yes (Go to #7)
[ ] No (Go to #6)
- Does the client have a history of atherosclerotic cardiovascular disease (ASCVD), heart failure (HF) or chronic kidney disease (CKD) in the last 365 days?
[ ] Yes (Go to #7)
[ ] No (Deny)
- Does the client have a history of ESRD, pancreatitis, gastroparesis, medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2) in the last 730 days?
[ ] Yes (Deny)
[ ] No (Go to #8)
- Does the client have a history of ESRD services (CPT codes) in the last 730 days?
[ ] Yes (Deny)
[ ] No (Go to #9)
- Does the client have a history of an HbA1c test in the last 180 days?
[ ] Yes (Go to #10)
[ ] No (Deny)
- Will the client have concurrent therapy with a GLP-1 RA containing agent?
[ ] Yes (Deny)
[ ] No (Approve – 365 days)
Prior authorization criteria for
Lovaza & Vascepa will be the following:
- Is the client greater than or equal to (³) 18 years of age?
[ ] Yes (Go to #2)
[ ] No (Deny)
- Does the client have a diagnosis of severe hypertriglyceridemia (TG ≥ 500mg/dL) in the last 365 days?
[ ] Yes (Go to #3)
[ ] No (And the request is for Vascepa, go to #4)
[ ] No (Deny)
- Has the patient failed a 30-day treatment trial with a fibrate in the last 180 days?
[ ] Yes (Go to #6)
[ ] No (Deny)
- Does the client have a diagnosis of elevated triglyceride levels (TG ≥ 150mg/dL) AND diabetes mellitus or established cardiovascular disease?
[ ] Yes (Go to #5)
[ ] No (Deny)
- Is the client currently on maximally tolerated statin therapy, or does the client have an intolerance or contraindication to statin therapy?
[ ] Yes (Go to #6)
[ ] No (Deny)
- Is the quantity requested less than or equal to (£) 4 units per day?
[ ] Yes (Approve – 365 days)
[ ] No (Deny)
Next steps for providers: Prescribers can find updated prior authorization for on
Navitus page. Prescribers should share this update with their staff
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.For access to all provider alerts,log into:
www.thecheckup.org or
www.texaschildrenshealthplan.org/for-providers
