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Update to TMPPM and the CSHCN Services Program Provider Manual for Leuprolide Acetate Effective March 1, 2025

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On March 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook, section 6.79, “Leuprolide Acetate (Lupron Depot),” and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Chapter 31, “Physician,” subsection 31.2.26.16, “Leuprolide Acetate Injection.”

The limitation for procedure code J1950 will change from once per calendar month to once every 28 days.

The reimbursement limitations for procedure code J9217 will be updated as follows:

FrequencyDosageLimitations
Monthly7.5 mg

Billed with a quantity of 1

Reimbursed once every 28 days

3-month22.5 mg

Billed with a quantity of 3

Reimbursed once every 84 days

4-month30 mg

Billed with a quantity of 4

Reimbursed once every 112 days

6-month45 mg

Billed with a quantity of 6

Reimbursed once every 168 days

Note: Prior authorization is required for procedure codes J1950, J9217, and J9218 for Texas Medicaid only.

CSHCN Provider Manual Update

Procedure code J1950 will be added to Chapter 31, “Physician,” subsection 31.2.26.16, “Leuprolide Acetate Injection.”

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.