HHSC will revise the clinical prior authorization criteria guides for enzymes on June 30, 2021, per recent US Food and Drug Administration changes. References will also be updated accordingly, including:
- HHSC will remove Adagen due to product discontinuation
- HHSC will remove Ceprotin 400-600 units vial because it is not covered through the outpatient pharmacy benefit
- HHSC will update the age requirement to cover clients 2 years of age and older
- HHSC will add the diagnosis of adenosine deaminase severe combined immunodeficiency disease (ADA-SCID) for Revcovi
The Enzyme clinical prior authorization criteria (PDF) is optional for MCOs. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to those used for processing fee-for-service Medicaid claims. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO’s list of clinical prior authorizations.