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Pegfilgrastim-cbqv (Udenyca) to be Diagnosis Restricted Effective May 1, 2022

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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 for dates of service on or after May 1, 2022, pegfilgrastim-cbqv (Udenyca; procedure code Q5111), a granulocyte colony stimulating factor, will be restricted by diagnosis.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.19, “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.