Reimbursement Updates for Certain Renal Dialysis Drugs Effective January 1, 2025

Date: February 7, 2025

Attention: All Providers

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after January 1, 2025, reimbursement for certain renal dialysis drugs have been updated.

Difelikefalin and Daprodustat

Difelikefalin (procedure code J0879) will be a benefit for clients who are 18 years of age or older when provided as follows:

Procedure code J0879 will be excluded from the composite rate and may be reimbursed separately.

Note: New benefits that are adopted by Texas Medicaid must be presented at a rate hearing to receive public comment on proposed Texas Medicaid reimbursement rates. After the rate hearing, expenditures must be approved before the rates are adopted by Texas Medicaid. Providers will be notified in a future article if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures are not approved.

Please note that, according to the Texas Medicaid & Healthcare Partnership (TMHP) article Update to “Reimbursement Updates for Certain Renal Dialysis Drugs Effective January 1, 2025”, the reimbursement for daprodustat (procedure code J0889) did not change on January 1, 2025.Procedure code J0889 is not a benefit of Texas Medicaid and will not be reimbursed.

Diagnosis Restrictions

Procedure code J0879 will be restricted to the following diagnosis codes:

Epoetin Alfa-epbx (Ratacrit)

Epoetin Alfa-epbx (Ratacrit) (procedure code Q5105) will be excluded from the composite rate and may be reimbursed separately.

Diagnosis Restrictions

Procedure code Q5105 will be restricted to the following diagnosis codes:

Next step for providers: Providers should share this communication 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.texaschildrenshealthplan.org/provideralerts.