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Update to Outpatient Drug Services Handbook for Hereditary Angioedema (HAE) Agents

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On June 1, 2023, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, section 6.42, “Hereditary Angioedema (HAE) Agents.”

The following procedure codes, age restrictions, and diagnosis code limitations will be added:

Description

Procedure Codes

Restrictions

C1 Esterase Inhibitor (Human) (Berinert)

J0597

Restricted to clients who are 5 years of age or older

Limited to diagnosis code D841

Ecallantide (Kalbitor)

J1290

Restricted to clients who are 12 years of age or older

Limited to diagnosis code D841

Icatibant injection (Firazyr)

J1744

Restricted to clients who are 18 years of age or older

Limited to diagnosis code D841

Lanadelumab-flyo (Takhzyro) (procedure code J0593) will be updated as follows:

  • The age restriction will change from 12 years of age or older to 2 years of age or older.
  • Diagnosis code D841 will be added.

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