HHSC will update the diagnosis codes in the Epidiolex clinical prior authorization criteria (PDF) for consistency with those diagnosis codes used for Diacomit. Both drugs are US Food and Drug Administration-approved treatments for Dravet Syndrome.
- G40411 – other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
- G40419 – other generalized epilepsy and epileptic syndromes, intractable without status epilepticus
- G40803 – other epilepsy, intractable, with status epilepticus
- G40804 – other epilepsy, intractable, without status epilepticus
This clinical prior authorization is optional for Medicaid MCOs. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to the authorizations 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