Non-Risk Based Status for Zynteglo Began July 1, 2023

Date: August 28, 2023

Attention: Physicians

Effective Date: July 1, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to let you know that effective July 1, 2023, reimbursement for Zynteglo is non-risk. Zynteglo (procedure code J3590) is a gene therapy for treating adult and pediatric clients with beta-thalassemia requiring regular blood cell (RBC) transfusions.

How this impacts providers: Zynteglo is administered in a qualifying treatment center (QTC) for clients that meet prior authorization criteria. QTC is required to send the prescription to the manufacturer-authorized specialty pharmacy, which will process the claim for Zynteglo. Texas Children’s Hospital Medical Center is the only active Qualified Treatment Center for Zynteglo at this time. MCOs will be reimbursed non-risk for Zynteglo when billed through the outpatient drug benefit. To be eligible for reimbursement, medical encounters must contain a Financial Arrangement Code of “20”. The clients’ inpatient hospitalization will be billed under diagnosis-related group (DRG) and is not eligible for non-risk reimbursement.

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.

Next steps for providers: Prescribers should share this communication with their staff. Provider must make sure to send the Zynteglo prescription to the manufacturer-authorized specialty pharmacy and the pharmacy will process the claim for the drug.

06/13/2024 Update: For information on the current maximum allowable reimbursement for Zynteglo, please review the following Provider Alert: https://www.thecheckup.org/2024/06/12/provider-alert-maximum-allowable-update-for-non-risk-based-drugs-billed-with-unclassified-procedure-codes/

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.