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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.76 Therapeutic Radiopharmaceuticals : 8.2.76.1 Prior Authorization for Therapeutic Radiopharmaceuticals

8.2.76.1
Prior authorization is not required for therapeutic radiopharmaceuticals except for tositumomab or ibritumomab tiuxetan.
Tositumomab or ibritumomab tiuxetan may be prior authorized when all of the following criteria are met:
Client has a diagnosis of either a low‑grade follicular or transformed B‑cell non‑Hodgkin’s lymphoma.
Prior authorization must be submitted through Special Medical Prior Authorization department.
Only one tositumomab or ibritumomab tiuxetan (procedure codes A9542, A9543, A9544, and A9545) may be prior authorized and reimbursed once per lifetime, any provider with diagnosis code 20280.

Texas Medicaid & Healthcare Partnership
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