The Vendor Drug Program (VDP) made changes to the Texas Medicaid drug formulary effective January 30, 2026. To learn more about formulary changes impacted, please click here for more information
Clinical Prior Authorization Criteria Revisions for Bylvay Scheduled for Nov. 21
Date: November 2, 2022
Attention: Providers
Effective Date: November 21, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to 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 (TCHP) will revise clinical prior authorization criteria for Bylvay. The new prior authorization (PA) criteria will be effective November 21, 2022. TCHP will change question 2 on the PA criteria from “Does the client have a diagnosis of progressive familial intrahepatic cholestasis (PFIC) confirmed with genetic testing? [Manual]” to “Does the client have a diagnosis of PFIC type 2 with ABCB11 variants resulting in the non-functional or complete absence of bile salt export pump protein (BSEP-3)?”
How this impacts providers: Effective November 21, 2022, the prior authorization criteria will be as follows:
- Is this a renewal request?
- Does the client have a diagnosis of PFIC type 2 with ABCB11 variants resulting in the non-functional or complete absence of bile salt export pump protein?
- Does the client have a history of a liver transplant?
- Does the client have a history of biliary diversion surgery in the last 180 days?
- Has the client had at least 90 days therapy in the last 180 days of a standard agent used for the treatment of cholestasis pruritis?
- Does the client have an alanine aminotransferase (ALT) and total bilirubin that is less than (<) 10 times the upper limit of normal (ULN)?
- Is the request for less than or equal to (≤) 5 capsules per day?