Clinical Prior Authorization Criteria Updates

Date: June 9, 2023

Attention: All Providers

Effective Date: March 23, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that the Texas Health and Human Services (HHSC) will be implementing updated clinical prior authorization criteria for Allergen extracts, IIleal Bile Acid Transporter (IBAT) Inhibitors and Monoclonal Antibody Agents.

Allergen Extracts

Palforzia is indicated for an allergic reaction that may occur with accidental exposure to peanut. Palforzia will require clinical criteria similar to that of other allergen extracts. The clinical criteria for Palforzia has been established. Please find updated forms on Navitus.
We would also like to inform you that several new codes have been added to document peanut allergy. Please take note of the following newly added ICD-10 codes for peanut allergy:
- T7801XA
- T7801XD
- T7801XS

Ileal Bile Acid Transporter (IBAT) Inhibitors

Cholestatic Pruritis Agents were renamed as Ileal Bile AcTransporterter (IBAT) Inhibitors on March 30, 2023. The updated classification as IBAT inhibitors is reflected in the Ileal Bile Acid Transport (IBAT) Criteria Guide and the prior authorization forms found on Navitus.

Monoclonal Antibody Agents criteria guide

Criteria for these agents was updated on March 23, 2023. Please see updates form on Navitus.

How this impacts providers: With this update from HHSC, providers need to be aware of the updated criteria to ensure compliance with prior authorization requirements.

Next steps for providers: Prescribers should share this communication with their staff. It is important for providers to be aware of the noted and updated changes above regarding HHSC updated clinical prior authorization criteria guides.

References:

If you have any questions, please email TCHP Pharmacy at: tchppharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.