Texas Medicaid Provider Procedures Manual August 2021 Provider Handbooks Outpatient Drug Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission. TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 AUGUST 2021 OUTPATIENT DRUG SERVICES HANDBOOK Table of Contents 1 General Information . 7 1.1 * About the Vendor Drug Program . 7 1.2 * Pharmacy Enrollment . 7 1.3 Program Contact Information. 8 2 Enrollment . 8 3 Services, Benefits, Limitations, and Prior Authorization. .8 3.1 Prior Authorization Requests . 8 3.2 Electronic Signatures in Prior Authorizations . 9 4 Reimbursement. 9 5 Injectable Medications as a Pharmacy Benefit. .10 6 National Drug Code (NDC) . .11 6.1 Calculating Billable HCPCS and NDC Units . .11 6.1.1 Single-Dose Vials Calculation Examples . 12 6.1.2 Multi-Dose Vials Calculation Examples . 12 6.1.3 Single and Multi-Use Vials . 13 6.1.4 Nonspecific, Unlisted, or Miscellaneous Procedure Codes . 13 7 Outpatient Drugs—Benefits and Limitations. .14 7.1 Abatacept (Orencia) . .14 7.1.1 Prior Authorization for Abatacept (Orencia) . 15 7.2 Adalimumab. .16 7.3 Ado-trastuzumab entansine (Kadcyla). .17 7.4 Alglucosidase Alfa (Myozyme) . .17 7.5 Amifostine . .18 7.6 Antibiotics and Steroids . .21 7.7 Antisense Oligonucleotides (eteplirsen, golodirsen, and nusinersen) . .22 7.7.1 Prior Authorization Requirements. 22 7.7.1.1 Initial Requests (for all Antisense Oligonucleotides) . 23 7.7.1.2 Recertification/Extension Requests (for all Antisense Oligonucleotides). 25 7.7.1.3 Exclusions . 26 7.8 Aripiprazole Lauroxil, (Aristada Initio). .26 7.9 Azacitidine (Vidaza) . .26 7.10 Belantamab Mafodontin-blmf . .26 7.11 Botulinum Toxin Type A and Type B . .26 7.12 Brexanolone (Zulresso) . .29 7.12.1 Risk Evaluation and Mitigation Strategy Program . 30 7.12.2 Prior Authorization Requirements. 30 7.13 Burosumab-Twza (Crysvita). .30 2 CPT ONLY - COPYRIGHT 2020 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. OUTPATIENT DRUG SERVICES HANDBOOK AUGUST 2021 7.14 Calaspargase Pegol-Mknl. .31 7.15 Cemiplimab-rwlc. .32 7.16 Chelating Agents . .32 7.16.1 Dimercaprol. 32 7.16.2 Edetate calcium disodium . 32 7.16.3 Deferoxamine mesylate (Desferal). 33 7.17 Chimeric Antigen Receptor (CAR) T-Cell Therapy . .33 7.17.1 Prior Authorization Criteria for Axicabtagene Ciloleucel (Yescarta). 34 7.17.2 Prior Authorization for Brexucabtagene autoleucel (Tecartus) . 34 7.17.3 Prior Authorization Criteria for Tisagenlecleucel (Kymriah) . 35 7.17.4 Exclusions. 36 7.18 Clofarabine . .36 7.18.1 Prior Authorization for Clofarabine . 36 7.19 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim). .36 7.20 Crizanlizumab-tmca (Adakveo) . .40 7.20.1 Prior Authorization . 40 7.21 Denileukin diftitox (Ontak) . .41 7.22 Dimethyl sulfoxide . .41 7.23 Eculizumab . .41 7.24 Edaravone (Radicava) . .41 7.25 Emapalumab-lzsg (Gamifant) . .41 7.25.1 Prior Authorization Requirements. 41 7.26 Enfortumab Vedotin-ejfv (Padcev) . .42 7.27 Eravacycline (Xerava) . .42 7.28 Esketamine (Spravato) . .42 7.28.1 Prior Authorization . 43 7.29 Fam-trastuzumab Deruxtecan-nxki . .44 7.30 Fluocinolone Acetonide (Retisert) . .44 7.31 Fremanezumab-vfrm. ..