Some Ustekinumab Drugs Will Be a Benefit of Texas Medicaid

Date: July 10, 2025

Attention: Providers

Effective date: July 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after July 1, 2025, the following procedure codes will be a benefit of Texas Medicaid:

• Ustekinumab-ttwe (Pyzchiva), subcutaneous, procedure code Q9996
• Ustekinumab-ttwe (Pyzchiva), intravenous, procedure code Q9997
• Ustekinumab-aekn (Selarsdi), procedure code Q9998
• Ustekinumab-aauz (Otulfi), procedure code Q9999

How this impacts providers: Procedure codes Q9996, Q9997, Q9998, and Q9999 will be limited to clients who are 6 years of age or older and restricted to the following diagnosis codes:

Texas Medicaid managed care organizations (MCOs) like TCHP must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their 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/providers.

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: www.texaschildrenshealthplan.org/provideralerts.