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Prior Authorization Criteria for Crizanlizumab-tmca (Adakveo) Effective July 1, 2020

Last updated on 6/5/2020

Note:Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after July 1, 2020, prior authorization will be required for crizanlizumab-tmca (Adakveo) (procedure code C9053) for Texas Medicaid.

Crizanlizumab-tmca (Adakveo) is indicated for clients with sickle cell disease to reduce the frequency of vaso-occlusive crises.

Crizanlizumab-tmca (Adakveo) must be prescribed by, or in consultation with, a hematologist or a sickle cell disease specialist.

Prior Authorization Requirements

Prior authorization requests for procedure code C9053 must be submitted with a Special Medical Prior Authorization Request Form, and may be approved for 12 months per prior authorization request.

Documentation of the client’s dosage, administration schedule, number of doses to be administered during the prior authorization period, the requested units per dose, and the dosage calculation must be submitted in Section C of the Special Medical Prior Authorization Request Form under Statement of Medical Necessity.

The Special Medical Prior Authorization Request Form must be completed, signed, and dated by the prescribing provider. The Special Medical Prior Authorization Form will not be accepted beyond 90 days from the date of the prescribing provider’s signature.

The completed Special Medical Prior Authorization Request Form must be maintained by the prescribing provider in the client's medical record and is subject to retrospective review.

Initial Therapy Requests

For initial therapy, all of the following criteria must be met:

  • The client is 16 years of age or older.
  • The client has a diagnosis of sickle cell disease of any genotype.
  • The client has experienced two or more vaso-occlusive events in the past 12 months.
  • Clients will not receive crizanlizumab-tmca (Adakveo) therapy concomitantly with voxelotor (Oxbryta).

Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy, the client must meet all of the following requirements:

  • The client continues to meet the following initial approval criteria:
    • The client is 16 years of age or older.
    • The client has a diagnosis of sickle cell disease of any genotype.
    • The client is not receiving crizanlizumab-tmca (Adakveo) therapy concomitantly with voxelotor (Oxbryta).
  • The client experienced a positive clinical response to therapy as demonstrated by reduced frequency of vaso-occlusive crisis.
  • The client has previously received treatment with crizanlizumab-tmca (Adakveo) without complications.

For more information, call the TMHP Contact Center at 800-925-9126.