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Retroactive Enrollment Claims Reprocessing

Medicaid providers are experiencing significant challenges complying with Medicaid provider enrollment revalidation requirements and timelines. In response, HHSC is implementing provider enrollment revalidation flexibilities and requiring all Medicaid and CHIP payers to support these flexibilities. HHSC is taking action to extend revalidation due dates, reduce or eliminate enrollment gaps and require payers to support claims reprocessing efforts.

More information: Retroactive Enrollment Periods and Claims Reprocessing.

For ProvidersNews & Updates

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HHSC Notifications

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    2021 News

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    2020 News

    • Semi-annual Medicaid Preferred Drug List Update Coming Jan. 28, 2021

      Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on Jan. 28, 2021. The update is based on changes presented and recommended at the July and October 2020 Texas Drug Utilization Review Board meetings. Drug list decisions from those meetings are available.

    • Medicaid Adds Pfizer BioNTech COVID-19 Vaccine to Formulary

      Rightcare follows the Texas VDP formulary. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of the Pfizer-BioNTech COVID-19 Vaccine on Dec. 11, 2020.

      HHSC will add the vaccine to the formulary for the Medicaid, Children's Health Insurance Program (CHIP) and Healthy Texas Women (HTW) programs as a payable pharmacy benefit beginning Dec. 28, 2020. VDP will backdate the effective date of formulary coverage to Dec. 11, 2020, to align with medical benefit requirements, meaning pharmacy claims with dates of service starting Dec. 11, 2020, are allowed beginning Dec. 28, 2020.

      Manufacturer Drug Name NDC
      Pfizer-BioNTech COVID-19 Vaccine EUA 59267-1000-01
    • Medicaid Adds Moderna COVID-19 Vaccine to Formulary

      Rightcare follows the Texas VDP formulary. The Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the use of the Moderna COVID-19 vaccine on Dec. 18, 2020.

      HHSC will add the vaccine to the formulary for the Medicaid, Children's Health Insurance Program (CHIP) and Healthy Texas Women (HTW) programs as a payable pharmacy benefit beginning Dec. 28, 2020. VDP will backdate the effective date of formulary coverage to Dec. 11, 2020, to align with medical benefit requirements, meaning pharmacy claims with dates of service starting Dec. 11, 2020, are allowed beginning Dec. 28, 2020.

      Manufacturer Drug Name NDC
      Moderna COVID-19 Vaccine EUA 80777-0273-10
    • Change to Thiazolidinediones Clinical Prior Authorization Begins Feb. 4, 2021

      RightCare follows the Texas VDP formulary. Beginning Feb. 4, 2021, Texas Medicaid will no longer subject Oseni, a combination of Thiazolidinediones (TZD) and Dipeptidyl Peptidase-4 (DPP-4) inhibitor drug, to the TZD clinical prior authorization criteria (PDF). Oseni is not recommended for patients with severe renal impairment or end-stage renal disease requiring dialysis. Therefore, the TZD criteria are deemed inappropriate for this drug. Oseni will continue to be subject to the DPP-4 Inhibitors clinical prior authorization criteria (PDF).

      This prior authorization is optional for use in Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart shows the prior authorization each MCO uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO's list of clinical prior authorizations.

    • Revision to Kalydeco Clinical Prior Authorization Begins Dec. 28, 2020

      RightCare follows the Texas VDP formulary. On Sept. 25, 2020, the FDA approved Kalydeco (ivacaftor) to treat children four months through six months of age with cystic fibrosis who have at least one cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation. Previously, Kalydeco was approved only for children six months and older. On Dec. 28, 2020, VDP will update the Kalydeco clinical prior authorization criteria to reflect the newly FDA-approved indication for use in children age four months to less than six months with at least one CFTR gene mutation responsive to Kalydeco.

      This prior authorization is optional for use in Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each health plans uses and how those authorizations relate to the authorizations used for traditional Medicaid claim processing. This chart is updated quarterly. Providers can also refer to the MCO Resources for links to each MCO's clinical prior authorizations.

    • Healthy Texas Women Now Offers Postpartum Services

      Healthy Texas Women (HTW) is a core women's health and family planning program for low income women without health insurance. Informational flyer.

    • July 2020 Preferred Drug List Revised Oct. 30, 2020

      The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Oct. 30, 2020.

    • Clinical Prior Authorization Assistance Chart Now Available

      RightCare follows the Texas VDP formulary. An update to the Clinical Prior Authorization Assistance Chart (PDF) is available.

      There are certain clinical prior authorizations that all MCOs are required to perform. Usage of other clinical prior authorizations will vary between health plans at the discretion of each MCO. Each prior authorization guide includes a description of the steps in the prior authorization evaluation process:

      • All steps from the criteria guide apply to traditional Medicaid claims processed by VDP
      • This assistance chart identifies which prior authorizations are utilized by each MCO and how those prior authorizations relate to those used by VDP

      For more information about each MCO's clinical prior authorization requirements, providers can:

      • Refer to the MCO Resources for a link to each MCO's active clinical prior authorizations
      • Refer to the Prescriber MCO Assistance Chart (PDF) for the prior authorization call center phone number unique to each MCO
    • October 2020 Drug Utilization Review Board Meeting Summary

      The Texas Drug Utilization Review Board met Oct. 22-23, 2020, to make recommendations about clinical prior authorizations and drugs to be included on the Texas Medicaid Preferred Drug List.

    • Mosquito Repellent Standing Order Usage Reminder

      RightCare follows the Texas VDP formulary. Texas Health and Human Services issued the Texas Medicaid Standing Order for Mosquito Repellent for people enrolled in Medicaid, CHIP and the Healthy Texas Women Program earlier this year. The standing order serves as a prescription and allows pharmacists to dispense mosquito repellent under its terms. People enrolled in these programs do not have to visit their healthcare provider to receive mosquito repellents. Pharmacies should use the standing order instead of contacting the healthcare provider for a prescription for mosquito repellent.

    • July 2020 Preferred Drug List Decisions Now Available

      The Texas Drug Utilization Review Board met Friday, July 24, 2020 to make recommendations about drugs to be included on the Medicaid preferred drug list. The approved list of decisions is now available. HHSC will incorporate the decisions from both the July and October 2020 board meetings into the January 2021 release of the preferred drug list.

    • Nov. 13: RightCare Update 2020
    • October 2020 NDC-to-HCPCS Crosswalk Now Available

      The quarterly NDC-to-HCPCS Crosswalk is now available for clinician-administered drug processing. The next new crosswalk will be available January 2021.

    • Branded Concerta Tablets Return to Non-Preferred Status Oct. 16, 2020

      Rightcare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status for brand Concerta products in the Stimulants drug class on April 23, 2020, in response to reported drug shortages. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred Methylphenidate ER tablet products, as well as the non-preferred brand Concerta products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas.

      VDP will restore the non-preferred status on the drugs below on Oct. 16, 2020, because of sufficient product availability. For a complete list of all preferred products in the Stimulants drug class, refer to the July 2020 Preferred Drug List. Contact vdp-formulary@hhsc.state.tx.us for questions or comments.

    • July 2020 Preferred Drug List Revised Sept. 8, 2020

      The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Sept. 17, 2020.

    • Inhaled Glucocorticoids Products Return to Non-Preferred Status on Sept. 18, 2020

      RightCare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status on April 1, 2020 in response to reported drug shortages for medications in the "Glucocorticoids, Inhaled" drug class. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred inhaled glucocorticoid products, as well as the non-preferred inhaled glucocorticoid products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred inhaled glucocorticoid products.

      Updating to correct non-preferred status for Asmanex HFA.

    • Insulin Products Return to Non-Preferred Status Sept. 18, 2020

      RightCare follows the Texas VDP formulary. VDP temporarily removed the non-preferred status on April 1, 2020 in response to reported drug shortages for insulin products in the "Hypoglycemics, Insulins" drug class. VDP will reverse this change in status because of sufficient availability in the market. VDP made this determination after verifying the current availability of the preferred insulin products, as well as the non-preferred insulin products through multiple sources such as ASHP, FDA, manufacturers, wholesalers and pharmacies in various regions around Texas. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred insulin products.

      Updating to correct non-preferred status for Novolin Flexpen.

    • July 2020 Preferred Drug List Revised Sept. 8, 2020

      The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective Sept. 8, 2020.

    • Certain COVID-19 Procedure Codes Implemented Retroactively
    • Hurricane Laura Information for Medicaid Providers
    • Epidiolex and Diacomit Clinical Prior Authorization Criteria Updates

      VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations.

      On Oct. 1, 2020, ICD-10 code G40.83 becomes available for Dravet Syndrome with the following sub-codes:

      • G40.833 for Dravet Syndrome, intractable with status epilepticus
      • G40.834 for Dravet Syndrome, intractable without status epilepticus.

      RightCare will update the clinical edits for Epidiolex and Diacomit to include these ICD-10 codes on Oct. 1, 2020. On July 31, 2020, the FDA approved Epidiolex for the treatment of seizures associated with tuberous sclerosis complex in patients one year of age and older. RightCare will add this new indication to the Epidiolex clinical edit on Oct. 1, 2020.

      RightCare's Clinical Edits.

    • Expansion of Pharmacy Benefit for Pharmacist Reimbursable Services Begins Sept. 1, 2020

      Beginning Sept. 1, 2020, RightCare will expand the Medicaid benefit to allow pharmacists to administer certain medications in a pharmacy setting, including the administration of:

      • certain long-acting anti-psychotics
      • opiate dependence treatments and emergency treatment for known or suspected opioid overdoses
      • flu vaccines
    • Deadline Extended for Medicaid/CHIP/Dentist Provider Relief Funding to Sept. 13, 2020
    • 2020-21 Respiratory Syncytial Virus Season Begins Oct. 1, 2020

      The 2020-21 Respiratory Syncytial Virus (RSV) begins Oct. 1, 2020, for many counties in Texas. RightCare will make the following changes this season to Synagis coverage and prior authorizations:

      • RightCare will not end-date NDCs for Synagis as in previous years and the drug will remain active on the formulary. Year-round access to Synagis on the formulary allows for consideration of off-season requests.
      • Access to Synagis for children in CHIP is available as a pharmacy benefit effective Sept. 1. The Medicaid prior authorization criteria also apply to CHIP. Synagis is not available as a medical benefit for CHIP.
      • RightCare will remove the prior authorization criteria for the specialist or sub-specialist prescribing.

      The schedule is staggered and is based on a patient's county of residence at the start of the RSV season. Refer to the Synagis season schedule for each region's start and end dates.

      RightCare Synagis Prior Authorization Forms

    • Opioid-Related Clinical Prior Authorization Criteria Updates for Sept. 1, 2020

      VDP regularly updates the clinical prior authorization criteria. These updates are necessary to help align VDP drug policies and prior authorization approval criteria with the latest information available on drug information packets, the federal or state regulations. RightCare will implement the following opioid prior authorization criteria revisions on Sept. 1, 2020, to align with the uniform opioid policy.

      Opioid Policy Criteria

      The Opioid Policy criteria will be implemented with the following:

      • Opioid naïve is defined as members who have taken opioids for a duration less than or equal to seven days in the prior 60-day period. For opioid naïve patients, RightCare must require a one-time authorization for:
        • - An opioid prescription which exceeds a ten-day supply
        • - A prescription for a long-acting opioid formulation
        • - A claim in which the total daily dose of opioids exceeds 90 MME
      • For members who no longer meet the definition of opioid naïve, an authorization will be required if the total daily dose of opioids exceeds 90 MME. If approved, the authorization is for a six-month duration.

      Opiate Over-Utilization Criteria

      The Opiate Over-utilization criteria will be revised Sept. 1, 2020. The criteria document was revised to include a question regarding cancer, sickle cell, palliative care and hospice care diagnosis. This change will align the prior authorization criteria with the new opioid policy.

      RightCare Clinical Edit

    • Inhaled Glucocorticoids Products Return to Non-Preferred Status Sept. 18, 2020

      RightCare temporarily removed the non-preferred status on April 2 in response to reported drug shortages for medications in the "Glucocorticoids, Inhaled" drug class. RightCare will reverse this change in status because of sufficient availability in the market. Beginning Sept. 18, 2020, the formulary will reflect the PDL status changes for all non-preferred inhaled glucocorticoid products.

    • Insulin Products Return to Non-Preferred Status on Sept. 18, 2020

      RightCare temporarily removed the non-preferred status on April 2 in response to reported drug shortages for insulin products in the "Hypoglycemics, Insulins" drug class. RightCare will reverse this change in status because of sufficient availability in the market. Beginning Sept. 18, 2020 the formulary will reflect the PDL status changes for all non-preferred insulin products.

    • State Medicaid Managed Care Advisory Committee Subcommittee Meetings Aug. 25-26, 2020
    • 5.28.1 Access to Network Providers Performance Standards Response to Comments
    • EPSDT and Requests for Extended Ophthalmoscopy
    • National Academy of State Health Policy Provider Survey

      HHSC is participating in the National Academy of State Health Policy (NASHP) Maternal Child Health Policy Innovation program and is seeking provider input to gain a better understanding of the current landscape for substance use identification, substance use disorder (SUD) treatment and referral practices for pregnant and postpartum women enrolled in Medicaid, CHIP (including CHIP-P) or the Healthy Texas Women Program. Your response to the below survey will assist HHSC in developing better training and communication around SUD identification, existing treatment benefits, as well as referral and intervention processes and analyzing whether benefit and policy changes are needed.

    • Status of Generic Albuterol Products Return to Non-preferred Aug. 28, 2020

      In response to reported drug shortages for albuterol products in the Bronchodilators, Short-Acting Beta Agonist Inhalers drug class, RightCare temporarily removed the non-preferred status from the generic formulations on March 20, 2020. RightCare will reverse this change in status because we determined sufficient availability in the market.

    • Change to Macrolide Preferred Drug List Prior Authorization Duration Set for Sept., 15 2020

      On Sept 15, 2020, RightCare will extend the non-preferred prior authorization duration for macrolides from 30 days to 90 days for people with a diagnosis of Gastroparesis, Cerebral Palsy Gastroparesis or GERD Gastrostomy complications. This will accommodate longer-term prescribing for such conditions.

    • Network Adequacy Corrective Action Plans
    • Send MCO Healthy Texas Women Materials by July 23
    • "Quantity Prescribed" Required for Schedule II Drugs Beginning Sept. 21

      Beginning Sept. 21, 2020, VDP will require the "Quantity Prescribed" field (460–ET) on all pharmacy claims for Schedule II drugs.

      CMS published a final rule(link is external) on Jan. 24, 2020, titled "Administrative Simplification: Modification of the Requirements for the Use of Health Insurance Portability and Accountability Act of 1996 National Council for Prescription Drug Programs D.0 Standard" requiring the "Quantity Prescribed" field (460–ET) when processing pharmacy claims for Schedule II drugs. The final rule applies to all health insurance plans, including Medicaid and CHIP.

    • Clinical Prior Authorization Update for Topical Immunomodulators Scheduled Aug. 13, 2020

      VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Eucrisa (crisaborole) criteria within the Topical Immunomodulators clinical prior authorization on Aug. 13, 2020:

      • Previously, Eucrisa was indicated for children 2 years of age and older. Recently, Eucrisa had an age extension for the treatment of mild to moderate topical dermatitis for children age 3 months and older.
      • Revised criteria will acknowledge this age change to allow children less than 2 years of age to receive Eucrisa without the requirement for a trial of a topical steroid

      RightCare Clinical Edits

    • Clinical Prior Authorization Update for VMAT2 Inhibitors Scheduled Aug. 13, 2020

      VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Austedo (deutetrabenazine) criteria within the Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors clinical prior authorization on Aug. 13, 2020:

      • Austedo is indicated for the treatment of tardive dyskinesia and Huntington-induced chorea. Current criteria require prescribing by or its use overseen by, a neurologist or psychiatrist
      • Revised criteria will remove the specialist requirement for only the treatment of tardive dyskinesia ◦ There will not be a change for the treatment of Huntington-induced chorea due to an increased risk of suicidality or suicidal ideation associated with Huntington disease

      RightCare Clinical Edits

    • Clinical Prior Authorization Update for Dupixent Scheduled Aug. 13, 2020

      VDP routinely updates existing clinical prior authorization criteria to reflect recent FDA-approved indications or safety information from the product package insert. RightCare will revise the Dupixent (dupilumab) clinical prior authorization on Aug. 13, 2020:

      • Current criteria allow prescribing for patients age 12 and older with moderate to severe atopic dermatitis
      • Revised criteria will allow prescribing for age 6 and older

      RightCare Clinical Edits

    • Semi-annual Medicaid Preferred Drug List Update Available July 30

      Preferred drugs are medications recommended by the Drug Utilization Review Board. The preferred drug list is published every January and July.

    • Updated COVID-19 FAQs – June 18
    • UMCM Updates for June 18
    • Timely Submission of State Fair Hearing Requests
    • MCO Questions: COVID-19 Updates
    • July 24 Drug Utilization Review Board Meeting Announcement
    • In-lieu-of Services Included Under the MCO Capitation Payment
    • Medicaid and CHIP Managed Care Provider Re-credentialing – COVID-19
    • Prior Authorization Criteria for Zulresso Begins July 1
    • Texas Health Steps Telemedicine Guidance for Providers: Answers to Common Questions Update
    • Enhanced Conversion Factor for Child Anesthesia Services for Qualifying Providers
    • Procedure Codes 54150 and 54160 to Become a Benefit for Additional Provider Types Effective Aug. 1
    • 2020 Prenatal Directory Template
    • Updated Guidance: CHIP Office Visit Co-Payments, Updated Reimbursement Process
    • Enrollment Broker Functions and Enrollment Process Training Scheduled for July 7
    • Resources for Neonatal Abstinence Syndrome Awareness Month
    • Texas Health Steps Telemedicine Guidance for Providers: Answers to Common Questions
    • Change in Status for the Platelet Aggregation Inhibitors Drug Class

      On May 28, RightCare temporarily revised the preferred drug list to address reported possible drug shortages of products in the Platelet Aggregation Inhibitors drug class. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. A list of the affected drugs is below. This is a temporary change until the preferred products are sufficiently available in the market. Prescribers are encouraged to use the VDP Formulary Search.

      Covered Drugs

      NDC Label Name
      43598033960 ASPIRIN-DIPYRIDAM ER 25-200 MG
      49884000702 ASPIRIN-DIPYRIDAM ER 25-200 MG
      62559085060 ASPIRIN-DIPYRIDAM ER 25-200 MG
      65162059606 ASPIRIN-DIPYRIDAM ER 25-200 MG
      70436009205 ASPIRIN-DIPYRIDAM ER 25-200 MG
      68462040560 ASPIRIN-DIPYRIDAM ER 25-200 MG
    • May 22, 2020: Texas Health Steps Computer-Based Training Now Available
    • Continuing Education Credit: Immunization
    • Drug Shortages of Nitrofurantoin Oral Suspension and Azithromycin Products

      RightCare has identified drug shortages of nitrofurantoin oral suspension and azithromycin products on the Medicaid and CHIP formularies. There are many other antibiotic choices available on the formulary and prescribers may choose an appropriate alternative based on patient diagnosis and indication for use. Prescribers are encouraged to use the VDP Formulary Search to identify other antibiotic options to avoid delays in people receiving medication.

    • Corrected Claim and Redetermination Memo - May 1, 2020

      Details on where to submit any corrected claims and redeterminations with a date of service prior to Nov. 1, 2019.

    • Temporary Change in Status for the Stimulants Drug Class Effective April 22, 2020

      HHSC has been informed of a drug shortage for Methylphenidate ER in the Stimulants drug class. RightCare temporarily removed the non-preferred status from the brand formulations of the NDCs below on April 22, 2020. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.

      NDC Label Name
      50458058501 CONCERTA ER 18 MG TABLET
      50458058601 CONCERTA ER 36 MG TABLET
      50458058701 CONCERTA ER 54 MG TABLET
      50458058801 CONCERTA ER 27 MG TABLET
    • PCSK9 Clinical Prior Authorization Criteria Changes To Begin May 22, 2020

      RightCare will revise the clinical prior authorization criteria for protein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on May 22, 2020.

      Clinical Edit Criteria

      Revisions include:

      • The LDL1 requirement for initiation of PCSK9 therapy was changed from greater than or equal to 130 mg/dL to greater than or equal to 70mg/dL
      • Diagnosis of Heterozygous Familial Hypercholesterolemia (HeFH) was replaced with the diagnosis of Primary Hyperlipidemia which includes HeFH diagnosis
      • The list of generic code numbers for atorvastatin and rosuvastatin was updated (Table 5)
      • References
    • Temporary Change in Status for Oral Immunosuppressives Drug Class Effective April 17, 2020

      The Food and Drug Administration announced a drug shortage for Tacrolimus, part of the in the Oral Immunosuppressives drug class. In response RightCare has temporarily removed the non-preferred status from the generic formulations of the NDCs below effective April 17. These changes will allow providers to prescribe for these drugs without requiring a PDL prior authorization and allow continued access to necessary medication for clients. This is a temporary change until the preferred products are sufficiently available in the market. RightCare will announce any further PDL status changes of these NDCs.

      NDC Label Name
      00469060773 PROGRAF 0.5 MG CAPSULE
      00469061773 PROGRAF 1 MG CAPSULE
      00469065773 PROGRAF 5 MG CAPSULE
      00469123050 PROGRAF 0.2 MG GRANULE PACKET
      00469133050 PROGRAF 1 MG GRANULE PACKET
    • RSV Season and Synagis Prior Authorization Ends April 14, 2020

      The 2019-20 respiratory syncytial virus season ends for all counties on April 14, 2020, and prior authorization requests for Synagis are no longer be accepted or reviewed.

    • Temporary Change in Status for Topical Nonsteroidal Anti-inflammatory Drugs Class Effective April 13, 2020

      RightCare has implemented the temporarily revised preferred drug list on April 13,2020, to address reported possible drug shortages of products in the Topical Nonsteroidal Anti-inflammatory drug class. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. This is a temporary change until the preferred products are sufficiently available in the market.

    • Ranitidine Products Removed from Formulary April 4, 2020

      The Food and Drug Administration requested manufacturers withdraw all ranitidine products (commonly known by the brand name Zantac) from the market because of consumer exposure to unacceptable levels of impurities. RightCare removed all ranitidine products from the Medicaid and CHIP formularies on April 4, 2020. Formulary alternatives available include famotidine (10mg, 20mg and 40mg), cimetidine (200mg, 300mg, 400mg and 800mg) and nizatidine (150mg and 300mg).

    • Temporary Change in Status for Inhaled Glucocorticoid, Insulin Hypoglycemics Drug Classes April 2, 2020

      RightCare has implemented the temporarily revised preferred drug list on April 2, 2020 to address reported possible drug shortages of products in the inhaled glucocorticoid and hypoglycemic insulin drug classes. The change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and people enrolled in Medicaid continued access to necessary medication. This is a temporary change until the preferred products are sufficiently available in the market.

    • Medicaid to Allow Expedited Pharmacy Enrollment Beginning April 1, 2020

      Beginning April 1, Texas pharmacies, as well as any out of state pharmacy, can temporarily enroll with the Vendor Drug Program using our expedited enrollment application (HHS Form 1350). The expedited form and enrollment process allows pharmacies to quickly provide pharmaceutical services to people enrolled in Texas Medicaid during the COVID-19 pandemic. In addition, CMS has waived the collection of the enrollment application fee during the state of emergency.

    • Revised Growth Hormone Clinical Prior Authorization Begins April 1, 2020

      RightCare will implement the Growth Hormone clinical prior authorization criteria on April 1, 2020.

      Clinical Edit Criteria

      The implementation will include four diagnosis codes for approval as suggested by MCOs and approved by VDP:

      • Q87.11: Prader-Willi Syndrome
      • Q87.19: Noonan Syndrome
      • E34.3: SHOX deficiency with Dyschondrosteosis
      • Q78.8: SHOX deficiency with short stature
    • Medicaid to Allow Expedited Pharmacy Enrollment Beginning April 1, 2020

      Beginning April 1, Texas pharmacies, as well as any out of state pharmacy, can temporarily enroll with the Vendor Drug Program using our expedited enrollment application (HHS Form 1350). The expedited form and enrollment process allows pharmacies to quickly provide pharmaceutical services to people enrolled in Texas Medicaid during the COVID-19 pandemic. In addition, CMS has waived the collection of the enrollment application fee during the state of emergency.

    • Albuterol Shortage Prompts Temporary Change in Preferred Status

      On March 21, VDP temporarily changed the preferred drug list to address reported drug shortages for short-acting agents in the bronchodilators, beta agonist drug class. This change allows providers to prescribe these drugs without requiring a non-preferred prior authorization and allow people on Medicaid continued access to necessary medication. VDP will continue to update providers on the status these drugs.

    • Sunosi Criteria Added to Central Nervous System Stimulants Clinical Prior Authorization Starting March, 9 2020

      RightCare implemented the clinical prior authorization criteria for Sunosi (solriamfetol) on March, 9 2020.

      Clinical Edit Criteria

      The criteria is part of the Central Nervous System Stimulants clinical prior authorization. The drugs Provigil and Nuvigil are already part of this clinical prior authorization.

    • New PDL Criteria Check Stage-Four Advance Metastatic Cancer Diagnosis

      RightCare added a new exception criteria to the Jan. 24 preferred drug list, to check for a diagnosis of stage-four advanced metastatic cancer or for treatment of symptoms associated with the cancer diagnosis. Prescribers must contact the pharmacy prior authorization call center and attest the person meets the exception criteria for the non-preferred drug to be approved because diagnoses are not readily available in a person's medical claims data.

      Clinical Edit Criteria

    • Cystic Fibrosis Agents Clinical Prior Authorization to Include Trikafta Criteria Starting Feb 24, 2020

      RightCare implemented the Trikafta criteria within the existing Cystic Fibrosis Agents clinical prior authorization on Feb 24, 2020.

      Clinical Edit Criteria

      The Texas Drug Utilization Board approved the criteria for Trikafta at the January 2020 meeting. Trikafta is a cystic fibrosis transmembrane conductance regulator (CFTR) modulating agent. As part of the criteria is a check for duplicative or concurrent therapies with another CTFR modulating agent. The board recommended the inclusion of this step to the criteria for all CFTR modulator agents.

    • 2020 Provider Reference Guide

      Refer to the Provider Reference Guide for information on claims, eligibility and other RightCare services.

    • Epinephrine Injection Drug Shortage Impacts Medicaid Non-Preferred Status

      Mylan issued an alert regarding the manufacturing challenges in the production of EpiPen (epinephrine injection, USP) 0.3 mg and EpiPen Jr (epinephrine injection, USP) 0.15 mg auto-injectors and the authorized generic versions of these strengths. These challenges resulted in the reduced availability of these products.

      RightCare temporarily removed the non-preferred status from the following:

      NDC Label Name
      00093598627 Epinephrine 0.3 mg auto-injector

      This change will allow providers to prescribe these product NDCs without requiring non-preferred prior authorization and will allow continued access to medication. The current preferred NDCs are:

      NDC Label Name
      00093598527 Epinephrine 0.15 mg auto-injector
      00115169449 Epinephrine 0.3 mg auto-injector
      00115169549 Epinephrine 0.15 mg auto-injector
      49502010101 Epinephrine 0.15 mg auto-injector
      49502010102 Epinephrine 0.15 mg auto-injector
      49502010201 Epinephrine 0.3 mg auto-injector
      49502010202 Epinephrine 0.3 mg auto-injector

      This is a temporary change until the preferred products are sufficiently available again in the market. There may be outages varying between pharmacies despite Mylan products no longer identified as a shortage according to FDA and ASHP. Further announcements regarding future PDL status changes of these NDCs will be sent out.

      Resources:

    • January 2020 Preferred Drug List Published

      The semi-annual update of the Medicaid preferred drug list is now available. The update is based on changes presented and recommended at the July and October 2019 Texas Drug Utilization Review Board meetings.

      Drugs on the Texas Medicaid formulary are designated as preferred, non-preferred or have neither designation. The preferred drug list includes only drugs identified as preferred or non-preferred.

    • Rinvoq Clinical Prior Authorization begins March 3

      RightCare will implement the Rinvoq (upadacitinib) clinical prior authorization criteria on March 3, 2020.

      Clinical Edit Criteria

      Rinvoq is a Janus Kinase inhibitor for treatment of adults with moderate-to-severe active rheumatoid arthritis who have not responded adequately or are intolerant, to methotrexate. The Texas DUR Board approved the criteria at the Oct. 2019 meeting.

    • Austedo Clinical Prior Authorization Criteria Revision Coming March 3

      RightCare will modify the Austedo prior authorization criteria on March 3, 2020. The criteria are included within the existing Vesicular Monoamine Transporter 2 (VMAT2) inhibitors criteria guide.

      Clinical Edit Criteria

      The Texas Drug Utilization Review Board approved the criteria in January 2014. The class includes Austedo, Xenazine and Ingrezza.

      Austedo is approved for treatment of Huntington-Induced Chorea and Tardive Dyskinesia (TD). RightCare will modify the prior authorization criteria to address the Austedo boxed warning about increased risk of depression in patients with only Huntington-Induced Chorea and prevent unnecessary prior authorization denials for patients with TD.

    • Allergen Extract Clinical Prior Authorization Revision Coming Feb. 24

      RightCare will revise the Allergen Extracts clinical prior authorization criteria on Feb. 24, 2020. This change reflects the Food and Drug Administration guidance expanding the indication for Oralair for people 5 years of age and older. The previous indication was for 10 years of age and older. Additionally, RightCare will change the contraindication diagnosis to include only severe, uncontrolled asthma diagnoses.

      Oralair is part of the Allergen Extract clinical prior authorization criteria.

      Clinical Edit Criteria

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