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Additional Diagnosis Code Allowed for Some Monoclonal Antibodies Effective May 1, 2024

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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.

Effective for dates of service on or after May 1, 2024, prior authorization requests for benralizumab (Fasenra), mepolizumab (Nucala), and reslizumab (Cinqair) will be considered when submitted with diagnosis code J8283.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.86.6, “Prior Authorization for Omalizumab, Benralizumab, Mepolizumab, Reslizumab, and Tezepelumab-ekko,” for additional diagnosis codes and criteria that may be considered for prior authorization.

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