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:

1. Is this a renewal request?

Yes (Go to #6) No (Go to #2)

2. 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?

Yes (Go to #3) No (Deny)

3. Does the client have a history of a liver transplant?

Yes (Deny) No (Go to #4)

4. Does the client have a history of biliary diversion surgery in the last 180 days?

Yes (Deny) No (Go to #5)

5. 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?

Examples of standard agents include cholestyramine (QUESTRAN, QUESTRAN LIGHT, PREVALITE), naltrexone, rifampin, sertraline (ZOLOFT), ursodiol (URSO, URSO FORTE) Yes (Go to #6) No (Deny)

6. Does the client have an alanine aminotransferase (ALT) and total bilirubin that is less than (<) 10 times the upper limit of normal (ULN)?

Yes (Go to #7) No (Deny)

7. Is the request for less than or equal to (≤) 5 capsules per day?

Yes (Approve-365 days) No (Deny) Next steps for providers: Updated PA forms will be found on Navitus page. Prescribers should share this communication 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: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.