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Age and Diagnosis Restriction Updates for Drug Procedure Codes and Update to Outpatient Drug Services Handbook

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 March 1, 2022, age and diagnosis restrictions were updated for the drug procedure codes listed in the sections below.

Age Restriction Updates

Procedure code J0596 is restricted to clients who are 13 years of age or older.

Procedure code J0598 and procedure code J0599 are restricted to clients who are 6 years of age or older.

Diagnosis Restriction Updates

Procedure codes J0596 and J0599 are restricted to diagnosis code D841.

Procedure code J9348 is no longer restricted by diagnosis.

Outpatient Drug Services Handbook to be Updated

Beginning April 1, 2022, the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook will be revised to include the updates listed in this article to drug procedure codes for age and diagnosis restrictions.

The table of diagnosis codes that is listed for procedure code J9119 in the Outpatient Drug Services Handbook, section 7.15, “Cemiplimab-rwlc,” will be removed. This procedure code is not restricted by diagnosis.

In addition, the following drugs will be added to the Outpatient Drug Services Handbook:

  • Amivantamab-vmjw (procedure code J9061)
  • Brolucizumab-dbll (procedure code J0179)
  • Cabotegravir and Rilpivirine (procedure code J0741)
  • Caffeine citrate (procedure code J0706)
  • Cefiderocol (procedure code J0699)
  • Coagulation factor XA (recombinant), inactivated-zhzo (procedure code J7169)
  • Daratumumab and hyaluronidase-fihj (procedure code J9144)
  • Degarelix injection (procedure code J9155)
  • Dostarlimab-gxly (procedure code J9272)
  • Eptinezumab-jjmr (procedure code J3032)
  • Evinacumab-dgnb (procedure code J1305)
  • Factor V11a (antihemophilic factor, recombinant-JNCW) (procedure code J7212)
  • Givosiran (procedure code J0223)
  • Imipenem, Cilastatin, and Relebactam (procedure code J0742)
  • Immune Globulin Xembify (procedure code J1558)
  • Isatuximab-irfc (procedure code J9227)
  • Lefamulin (procedure code J0691)
  • Lumasiran (procedure code J0224)
  • Loncastuximab tesirine-lpyl (procedure code C9084)
  • Lurbinectedin (procedure code J9223)
  • Margetuximab-cmkb (procedure code J9353)
  • Meloxicam (procedure code J1738)
  • Melphalan Evomela (procedure code J9246)
  • Mitomycin for pyelocalyceal solution (procedure code J9281)
  • Naxitamab-gqgk (procedure code J9348)
  • Pegaspargase injection (procedure code J9266)
  • Polatuzumab vedotin (procedure code J9309)
  • Prothrombin complex, human (procedure code J7168)
  • Rilonacept (procedure code J2793)
  • Sacituzumab govitecan-hziy (procedure code J9317)
  • Trilaciclib (procedure code J1448)

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