Age and Diagnosis Restriction Updates for Cabenuva, Oncaspar, Zulresso

Date: September 22, 2022 Attention: All ProvidersEffective Date: October 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with 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’s (TCHP) would like to inform providers that effective October 1, 2022, the age and diagnosis restrictions for Cabenuva (J0741), Zulresso (J1632), and Oncaspar (J9266) will be updated. How this impacts providers: Age and diagnosis restrictions will be as follows: The age restriction for Cabenuva (Cabotegravir and Rilpivirine), procedure code J0741 will become available for clients who are 12 years or older

• The age restriction for Zulresso (Brexanolone), procedure code J1632, will become available to include clients 15 years and older.
• Oncaspar (Pegaspargase) injection, procedure code J9266, will be restricted to the following diagnosis codes C9102, C9100 and C9101.

Next steps for providers: 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: Providers are encouraged to share this information with their staff. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org. For access to all provider alerts,log into: http://www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.