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Texas Medicaid Diagnosis Restrictions for Tocilizumab-bavi (Tofidence) Effective October 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 October 1, 2024, tocilizumab-bavi (Tofidence), procedure code Q5133, is restricted to the following diagnosis codes:

Diagnosis Codes
M0510M05111M05112M05119M05121M05122M05129
M05131M05132M05139M05141M05142M05149M05151
M05152M05159M05161M05162M05169M05171M05172
M05179M0519M0520M05211M05212M05219M05221
M05222M05229M05231M05232M05239M05241M05242
M05249M05251M05252M05259M05261M05262M05269
M05271M05272M05279M0529M0530M05311M05312
M05319M05321M05322M05329M05331M05332M05339
M05341M05342M05349M05351M05352M05359M05361
M05362M05369M05371M05372M05379M0539M0540
M05411M05412M05419M05421M05422M05429M05431
M05432M05439M05441M05442M05449M05451M05452
M05459M05461M05462M05469M05471M05472M05479
M0549M0550M05511M05512M05519M05521M05522
M05529M05531M05532M05539M05541M05542M05549
M05551M05552M05559M05561M05562M05569M05571
M05572M05579M0559M0560M05611M05612M05619
M05621M05622M05629M05631M05632M05639M05641
M05642M05649M05651M05652M05659M05661M05662
M05669M05671M05672M05679M0569M0570M05711
M05712M05719M05721M05722M05729M05731M05732
M05739M05741M05742M05749M05751M05752M05759
M05761M05762M05769M05771M05772M05779M0579
M057AM0580M05811M05812M05819M05821M05822
M05829M05831M05832M05839M05841M05842M05849
M05851M05852M05859M05861M05862M05869M05871
M05872M05879M0589M058AM059M0600M06011
M06012M06019M06021M06022M06029M06031M06032
M06039M06041M06042M06049M06051M06052M06059
M06061M06062M06069M06071M06072M06079M0609
M060AM0680M06811M06812M06819M06821M06822
M06829M06831M06832M06839M06841M06842M06849
M06851M06852M06859M06861M06862M06869M06871
M06872M06879M0689M068AM069M0800M0820
M08211M08212M08219M08221M08222M08229M08231
M08232M08239M08241M08242M08249M08251M08252
M08259M08261M08262M08269M08271M08272M08279
M0829M082AM083M0880M0890  

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