Date: May 27, 2025
Attention: Specialty Pharmacy Providers
Effective date: July 1, 2025
Call to action: Texas Children’s Health Plan (TCHP) would like to make specialty pharmacies aware the effective for dates of service on or after July 1, 2025, betibeglogene autotemcel (Zynteglo) (procedure code J3393) may be distributed through specialty pharmacy providers.
How this impacts providers: Prior authorization is required and may be approved for a duration of 12 months.
Texas Medicaid managed care organizations (MCOs) like TCHP must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in our MCO/TCHP. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should reference a member’s specific MCO/TCHP for information on these items. For TCHP, this information can be found on the provider page available here https://www.texaschildrenshealthplan.org/provider.
Next step for Providers: Providers should share this communication with their staff.
If you have any questions, please email TCHP Pharmacy at: tchppharmacy@texaschildrens.org.
For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.