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Age and Diagnosis Restriction Updates for Cabotegravir and Rilpivirine (Cabenuva) and Pegaspargase (Oncaspar)

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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 October 3, 2022, TMHP will update age and diagnosis restrictions for cabotegravir and rilpivirine (Cabenuva) (procedure code J0741) and pegaspargase (Oncaspar) (procedure code J9266).

  • Procedure code J0741 for Cabenuva will be restricted to clients who are 12 years of age or older.
  • Diagnosis code C9102 will be added as a payable diagnosis for procedure code J9266 for Oncaspar.

On November 1, 2022, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, section 6.17, “Cabotegravir and Rilpivirine (Cabenuva),” and section 6.11.2, “Pegaspargase (Oncaspar).”

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