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Cytokine and CAM Antagonists Criteria Updates Scheduled for April 5, 2022

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On April 5, 2022, the Texas Health and Human Services Commission (HHSC) will make the following revisions to various medications within the Cytokine and CAM Antagonists clinical prior authorization criteria, to ensure alignment with US Food and Drug Administration approved indications:

  • Cosentyx
    • Add diagnosis of enthesitis-related arthritis for patients greater than or equal to 4 years.
    • Add diagnosis of ankylosing spondylitis, remove a check for methotrexate/DMARDs, and add a check for prior therapy with a TNF-blocker.
  • Enbrel
    • Correct the logic diagram: Step 6 is renumbered, and the age changed is to 2 years.
  • Orencia
    • Add diagnosis for prophylaxis of acute graft versus host disease in patients greater than or equal to 2 years, in combination with a calcineurin inhibitor and methotrexate.
  • Otezla
    • Remove “moderate to severe” from plaque psoriasis.
  • Rinvoq
    • Add diagnosis of psoriatic arthritis, remove a check for methotrexate, and add a check for prior therapy with a TNF-blocker.
    • Add diagnosis of atopic dermatitis and add a check for prior therapy with a systemic agent for atopic dermatitis.
  • Skyrizi
    • Add diagnosis of psoriatic arthritis.
  • Xeljanz
    • Update question 1: Is the client’s age greater or equal to 2 years? A negative will result in a denial.

The Cytokine and CAM antagonists clinical prior authorization is optional for managed care organizations (MCOs). The Pharmacy Clinical Prior Authorization Assistance Chart indicates which prior authorization each MCO uses. The 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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