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.
Effective for dates of service on or after August 1, 2023, prior authorization criteria will be updated for monoclonal antibody procedure codes J0517, J2182, J2356, J2357, and J2786.
Additional Requirement for All Monoclonal Antibodies
A client with preexisting helminth infections should be treated prior to receiving omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko therapy.
If there is active helminth infection, the client should be treated with anti-helminth treatment. If there is no response, treatment should be discontinued until the parasitic infection resolves.
Documentation supporting medical necessity for treatment of eosinophilic granulomatosis with polyangiitis (EGPA) must include the following additional criteria:
The client has been on an oral glucocorticoid and/or cyclophosphamide, azathioprine, methotrexate, or leflunomide.
Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, section 6.65.6, “Prior Authorization for Omalizumab, Benralizumab, Mepolizumab, Reslizumab, and Tezepelumab-ekko,” for more EGPA treatment requirements.
Prior Authorization Criteria for Asthma — Moderate to Severe and Severe
Documentation supporting medical necessity for treatment of asthma with omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko must be submitted with the prior authorization request. The criteria that must be indicated in the documentation will change to the following:
Symptoms are inadequately controlled with use of a minimum of 3 months of controller medication (which includes but is not limited to a long-acting beta2-agonist [LABA], an inhaled or oral corticosteroid, leukotriene receptor antagonist [LTRA], or theophylline), unless the individual is intolerant of or has a medical contraindication to these agents.
Exceptions to the criteria will be considered on a case-by-case basis, which will require a letter from the prescribing provider stating the medical necessity for omalizumab, benralizumab, mepolizumab, or reslizumab, the client’s asthma severity level, and the duration of current and past therapies and lack of asthma control. Consideration for these exceptions will be reviewed by the TMHP medical director.
There will no longer be any additional documentation requirements for treatment with benralizumab, mepolizumab, or reslizumab.
Continuation of Therapy for Tezepelumab-ekko
Continuation of therapy requirements for tezepelumab-ekko will be the same as for all other monoclonal antibodies.
Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, section 6.65.8, “Requirements for Continuation of Therapy for Omalizumab, Benralizumab, Mepolizumab, or Reslizumab,” for continuation of therapy requirements for monoclonal antibodies.
For more information, call the TMHP Contact Center at 800-925-9126.