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 April 1, 2021, pegfilgrastim-apgf (Nyvepria) (procedure code Q5122) is a benefit of Texas Medicaid.
Pegfilgrastim-apgf (Nyvepria) (procedure code Q5122) is a granulocyte colony stimulating factor, and is diagnosis restricted.
Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.18, “Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim),” for a list of payable diagnosis codes for colony stimulating factors.
For more information, call the TMHP Contact Center at 800-925-9126.