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Some Ustekinumab Drugs Will Be a Benefit of Texas Medicaid Effective July 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.

Effective for dates of service on or after July 1, 2025, the following procedure codes will be a benefit of Texas Medicaid:

  • Ustekinumab-ttwe (Pyzchiva), subcutaneous, procedure code Q9996
  • Ustekinumab-ttwe (Pyzchiva), intravenous, procedure code Q9997
  • Ustekinumab-aekn (Selarsdi), procedure code Q9998
  • Ustekinumab-aauz (Otulfi), procedure code Q9999

Procedure codes Q9996, Q9997, Q9998, and Q9999 will be limited to clients who are 6 years of age or older and restricted to the following diagnosis codes:

Diagnosis Codes
K5000K50011K50012K50013K50014K50018K50019K5010
K50111K50112K50113K50114K50118K50119K5080K50811
K50812K50813K50814K50818K50819K5090K50911K50912
K50913K50914K50918K50919K5100K51011K51012K51013
K51014K51018K51019K5120K51211K51212K51213K51214
K51218K51219K5130K51311K51312K51313K51314K51318
K51319K5180K51811K51812K51813K51814K51818K51819
K5190K51911K51912K51913K51914K51918K51919L400
L401L402L403L404L4050L4051L4052L4053
L4054L4059L408L409    

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