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Epidiolex Prior Authorization Revision Set For May 11, 2021

Last updated on 3/19/2021

The Texas Health and Human Services Commission (HHSC) will update the diagnosis codes in the Epidiolex clinical prior authorization criteria for consistency with those diagnosis codes used for Diacomit. Both drugs are U.S. Food and Drug Administration-approved treatments for Dravet Syndrome.

The following updates will be made:

  • G40411
    • Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
  • G40419
    • Other generalized epilepsy and epileptic syndromes, intractable without status epilepticus
  • G40803
    • Other epilepsy, intractable, with status epilepticus
  • G40804
    • Other epilepsy, intractable, without status epilepticus

This clinical prior authorization is optional for managed care organizations (MCOs). The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses and how those authorizations relate to those used for processing fee-for-service Medicaid claims. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO’s list of clinical prior authorizations.

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