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Revisions to Cytokine and CAM Antagonists Prior Authorization Criteria Set for May 4, 2021

Last updated on 3/19/2021

Medicaid will revise Cytokine and Cell-Adhesion Molecule (CAM) Antagonists clinical prior authorization criteria on May 4, 2021 in accordance with the recent U.S. Food and Drug Administration’s changes. The revised clinical prior authorization criteria document is available for review.

The Texas Health and Human Services Commission (HHSC) will make the following revisions to several of the Cytokine and CAM Antagonist agents:

  • Actemra
    • HHSC will remove cytokine releasing syndrome as a diagnosis from the criteria because IV infusion formulation (Actemra 20 mg/ml) is not covered through the pharmacy benefit and health-care practitioners must administer.
  • Cimzia
    • HHSC will add question #3 to check for a trial of conventional therapy for Crohn’s disease prior to initiation of Cimzia.
  • Humira
    • HHSC will change the age check from 6 to 5 years of age for the diagnosis of ulcerative colitis (UC).
  • Ilaris
    • Question #2: HHSC will add active Still’s disease to criteria logic (diagnosis already included in ICD-10 table).
  • Kineret
    • Question #5: HHSC will add deficiency of interleukin-1 receptor antagonist (DIRA) as an approval diagnosis to criteria.
  • Simponi Aria
    • Question #6: HHSC will add polyarticular juvenile idiopathic arthritis (PJIA) and psoriatic arthritis (PsA) as approval diagnosis for patients equal to or greater than 2 years of age.

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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