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News & Updates

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Provider/Physician Notice

View the COVID-19 Telehealth and Telemedicine Policy for coding guidelines and claims submission procedures. We have also reduced our Prior Authorization Requirements.

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2021 News

IVR and Provider Portals for Member Information.

For more Information please click here.

Monoclonal Antibody for Asthma Prior Authorization Updates Set for April 6, 2021.

For more Information please click here.

Revised Hepatitis C Drug Prior Authorization Forms Now Available.

For more Information please click here.

Clinical Prior Authorization Updates for Cystic Fibrosis Agents.

For more Information please click here.

Preferred Drug List Criteria Exception for Macrolides Changes March 15.

For more Information please click here.

Renewed Texas Standing Order for Mosquito Repellent Benefit Available.

For more Information please click here.

Clinical Prior Authorization Assistance Chart Now Available For.

For more Information please click here.

January 2021 Preferred Drug List Now Available.

For more Information please click here.

COVID-19 Vaccine Facts.

For more Information please click here.

Desmopressin Clinical Prior Authorization Revision Begins March 15, 2021.

For more Information please click here.

COVID-19 Vaccine NDC Update.

For more Information please click here.

Dupixent Clinical Prior Authorization Criteria Revision Effective March 15, 2021.

For more Information please click here.

Quality Improvement webinar for ADHD HEDIS Measure (Initiation Phase).

Portia Green, SWHP’s Clinical Quality Improvement Coordinator, will host a presentation on follow-up care for children prescribed medications for attention-deficit hyperactivity disorder. This presentation is part one of a two-part series on the initiation and continuation phases of ADHD treatment.

For more Information please click here.

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2020 News

Semi-annual Medicaid Preferred Drug List Update Coming January 28, 2021

Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on January 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.

For additional information click here.

July 2020 Preferred Drug List Revised December 16, 2020

The July 30, 2020 Texas Medicaid Preferred Drug List was revised, effective December 16, 2020.

For additional information click here.

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 December 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 December 28, 2020. VDP will backdate the effective date of formulary coverage to December 11, 2020 to align with medical benefit requirements, meaning pharmacy claims with dates of service starting December 11, 2020are allowed beginning December 28, 2020

Manufacturer	Drug Name	NDC
Pfizer-BioNTech	COVID-19 Vaccine EUA	59267-1000-01

For additional information click here.

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 December 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 December 28, 2020. VDP will backdate the effective date of formulary coverage to December 11, 2020 to align with medical benefit requirements, meaning pharmacy claims with dates of service starting December 11, 2020 are allowed beginning December 28, 2020.

Manufacturer	Drug Name	NDC
Moderna	COVID-19 Vaccine EUA	80777-0273-10

For additional information click here.

Change to Thiazolidinediones Clinical Prior Authorization Begins February 4, 2021

RightCare follows the Texas VDP formulary. Beginning February 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)(link is external). 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)(link is external).

This prior authorization is optional for use in Medicaid managed care. 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 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.

For additional information click here.

Revision to Kalydeco Clinical Prior Authorization Begins December 28, 2020

RightCare follows the Texas VDP formulary. On September 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 December 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.

For additional information click here.

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 October 30, 2020

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

For additional information click here.

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

For additional information click here.

October 2020 Drug Utilization Review Board Meeting Summary

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

For additional information click here.

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.

For additional information click here.

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.

For additional information click here.

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.

Click here for information.

Branded Concerta Tablets Return to Non-Preferred Status on October 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 October 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, 2020 Preferred Drug List. Contact vdp-formulary@hhsc.state.tx.us (link sends e-mail) for questions or comments.

For additional information and a list of preferred PDL NDCs, please click here.

July 2020 Preferred Drug List Revised September 8, 2020

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

For additional information click here.

Inhaled Glucocorticoids Products Return to Non-Preferred Status on September 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 September 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.

For additional information and a list of preferred PDL NDCs please click here.

Insulin Products Return to Non-Preferred Status on September 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 September 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.

For additional information and a list of preferred PDL NDCs please click here.

July 2020 Preferred Drug List Revised September 8, 2020

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

For additional information Click here.

Certain COVID-19 Procedure Codes Implemented Retroactively

Click here.

Hurricane Laura Information for Medicaid Providers

click here.

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 October 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 October 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 October 1, 2020.

For RightCare’s Clinical Edits click here.

Expansion of Pharmacy Benefit for Pharmacist Reimbursable Services Begins September 1, 2020

Beginning September 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

For more information please click here.

Deadline Extended for Medicaid/CHIP/Dentist Provider Relief Funding to September 13, 2020

Click here.

2020-21 Respiratory Syncytial Virus Season Begins October 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. For additional information please click here.

RightCare Synagis Prior Authorization forms will be posted here on September 1,2020.

Opioid-Related Clinical Prior Authorization Criteria Updates for September 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 September 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.

For RightCare clinical edits, please click here.

July 2020 Drug Utilization Review Board Meeting Summary

The Texas Drug Utilization Review Board met recently to make recommendations about clinical prior authorizations and the preferred drug list. For additional information please click here.

Inhaled Glucocorticoids Products Return to Non-Preferred Status on September 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 September 18, 2020 the formulary will reflect the PDL status changes for all non-preferred inhaled glucocorticoid products. For additional information and a list of preferred PDL NDCs please click here.

Insulin Products Return to Non-Preferred Status on September 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 September 18, 2020 the formulary will reflect the PDL status changes for all non-preferred insulin products. For additional information and a list of preferred PDL NDCs please click here.

State Medicaid Managed Care Advisory Committee Subcommittee Meetings August 25 and 26, 2020

Click here.

5.28.1 Access to Network Providers Performance Standards Response to Comments

Click here.

EPSDT and Requests for Extended Ophthalmoscopy

Click here.

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.

The survey can be found here and is available until August 31, 2020.

Status of Generic Albuterol Products Return to Non-preferred August 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. For more information including the preferred PDL options, click here.

Change to Macrolide Preferred Drug List Prior Authorization Duration Set for September, 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. For more information please click here.

Network Adequacy Corrective Action Plans

Click here.

Send MCO Healthy Texas Women Materials by July 23

Click here.

"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. For more information click here.

Clinical Prior Authorization Update for Topical Immunomodulators Scheduled for August 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 August 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

For RightCare clinical edits please click here.

Clinical Prior Authorization Update for VMAT2 Inhibitors Scheduled for August 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 August 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

For RightCare clinical edits pleas click here.

Clinical Prior Authorization Update for Dupixent Scheduled for August 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 August 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

For RightCare clinical edits please click here.

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. For additional information please click here.

Updated COVID-19 FAQs – June 18

Click here.

UMCM Updates for June 18

Click here.

Timely Submission of State Fair Hearing Requests

Click here.

MCO Questions: COVID-19 Updates

Click here.

July 24 Drug Utilization Review Board Meeting Announcement

Click here.

In-lieu-of Services Included Under the MCO Capitation Payment

Click here.

Medicaid and CHIP Managed Care Provider Re-credentialing – COVID-19

Click here.

Prior Authorization Criteria for Zulresso Begins July 1

Click here.

Texas Health Steps Telemedicine Guidance for Providers: Answers to Common Questions Update

Click here.

Enhanced Conversion Factor for Child Anesthesia Services for Qualifying Providers

Click here.

Procedure Codes 54150 and 54160 to Become a Benefit for Additional Provider Types Effective Aug. 1

Click here.

Clinical Prior Authorization for Oxbryta in Traditional Medicaid Begins Sept. 8, 2020

VDP will implement the clinical prior authorization criteria for Oxbryta (voxelotor) for traditional Medicaid on Sept. 8. The Texas Drug Utilization Review Board approved Oxbryta as part of the Sickle Cell Disease Agents criteria (PDF) at its Jan. 2020 meeting. This prior authorization is optional for Medicaid managed care. The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) shows the prior authorization each MCO uses and how those authorizations relate to traditional Medicaid claim processing. This chart is updated quarterly and available on the VDP website. For RightCare clinical edits please click here.

2020 Prenatal Directory Template

Click here.

Updated Guidance: CHIP Office Visit Co-Payments, Updated Reimbursement Process

Click here.

Enrollment Broker Functions and Enrollment Process Training Scheduled for July 7

Click here.

Resources for Neonatal Abstinence Syndrome Awareness Month

Click here.

Texas Health Steps Telemedicine Guidance for Providers: Answers to Common Questions

Click here.

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. Click here for 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

05-22-2020 Texas Health Steps Computer-Based Training Now Available

Click here.

Continuing Education Credit: Immunization

Click here.

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, click here 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 11/01/2019. For more information please click here.

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. All clinical edit criteria can be found here.

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

For more information please click here.

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. For a list of affected drugs click here. 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). For more information click here.

Temporary Change in Status for Inhaled Glucocorticoid, Insulin Hypoglycemics Drug Classes on 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. For the list of the affected drugs click here. 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. For more additional please visit the Vendor Drug Program Website: here.

Revised Growth Hormone Clinical Prior Authorization Begins April 1, 2020

RightCare will implement the Growth Hormone clinical prior authorization criteria on April 1, 2020. All clinical edit criteria can be found here. 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. For more additional please visit the Vendor Drug Program Website: here.

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. Additional information can be found here.

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. All clinical edit criteria can be found here.

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. All clinical edit criteria can be found here.

HHS Seeking to Incresae LARC Utilization

In its ongoing efforts to promote women’s health, Texas Health and Human Services (HHS) is raising awareness of long-acting reversible contraception (LARC). The American College of Obstetricians and Gynecologists (ACOG) identifies LARCs, including intrauterine devices and subdermal contraceptive devices, as the most effective reversible contraceptive method. Requiring no action on the part of the person after the device is in place, LARCs have high rates of user satisfaction and method continuation. HHS has made improving access to LARCs a priority. More information can be found here.

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. All clinical edit criteria can be found here.

The Texas Drug Utilization Board approved the criteria for Trikafta at the Jan 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 and can be found here.

Rinvoq Clinical Prior Authorization begins March 3

RightCare will implement the Rinvoq (upadacitinib) clinical prior authorization criteria on March 3, 2020. All clinical edit criteria can be found here. New Rinvoq criteria will be included within the existing Cytokine and CAM Antagonists criteria guide.

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. All clinical edit criteria can be found here. 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 February 24

RightCare will revise the Allergen Extracts clinical prior authorization criteria on February 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. All clinical edit criteria can be found here.

2019 News

Semi-annual Medicaid Preferred Drug List Update Coming in January

Texas Medicaid will publish the semi-annual update of the Medicaid preferred drug list on January 27, with changes effective January 30. The update is based on changes presented and recommended at recent Texas Drug Utilization Review Board meetings. Visit the Vendor Drug Program website for a list of noteworthy changes in this update.

Nov. 4: RightCare Update Fall 2019

Nov. 1: RightCare—Authorization Requirement for Therapies

Effective November 1, 2019, we encourage all of our providers to utilize the RightCare Self-Service Provider Portal — rightcare.firstcare.com — to submit new authorization requests, view authorization status, and view prior authorization requirements. This online authorization process provides an immediate decision when clinical criteria meet for medical necessity.

Read the notice here.

DSHS Laboratory Web Portal

On Oct. 25, the Texas Department of State Health Services (DSHS) Laboratory reported that the Laboratory Web Portal application for public health microbiology and clinical chemistry results experienced unexpected technical difficulties and is currently shutdown.

Read the notice here.

Announcement: Congenital Syphilis Health Advisory

New state legislation was enacted on Sept. 1, 2019 to increase syphilis testing in pregnant women. Testing is now mandated at first prenatal care examination, during third trimester (no earlier than 28 weeks gestation) and at delivery.Read the notice here.

Announcement: Summary of smoking cessation benefits in Medicaid and CHIP

As a reminder, screening and basic information about tobacco cessation is an expected part of any routine visit with a healthcare provider. Additional services or supports are available through Medicaid & CHIP. Read the notice here.

Announcement: Medication Assisted Treatment (MAT) benefits to change for Texas Medicaid Nov. 1, 2019.

As part of the implementation of SB1564 (86R) Texas Medicaid is adding reimbursement for appropriately trained, advanced practice registered nurses who deliver Medication Assisted Treatment (MAT) in the office setting. Additionally, the public will be given the opportunity to provide comment regarding H2010 being directly replaced with H0033 for non-methadone MAT administration.Read the notice here.

Announcement: Tobacco Cessation Counseling Changes for Texas Medicaid

Effective for dates of service on or after May 1, 2019, smoking and tobacco use cessation counseling benefits will change for Texas Medicaid. Read the notice here.

Announcement: Scott and White Health Plan Provider Relations Representative Contact Information

To find the Provider Relations Representative for your county, please see the Provider Relations Representative Territory Map.

Oct. 1: New Prior Authorization update effective Nov. 1, 2019.

Read the notice here.

Sports Physicals: RightCare covers sports physicals as a value-added service. If a sports physical is requested and the child is due for a Texas Health Steps checkup, the checkup including all the required Texas Health Steps components should be completed as well. Providers may be reimbursed for sports physicals performed at the same time as a Texas Health Steps checkup or during a separate medical visit.

Span of Coverage Clarification: The purpose of this notice is to clarify the Span of Coverage policy for hospital transfers.

Read the notice here.

June 1: New Prior Authorization update effective June 1, 2019.

Click here for the announcement.

May 1: Revised Texas Medicaid Standing Order for Mosquito Repellent Benefit

The Texas Medicaid Standing Order for Mosquito Repellent has been revised and is available for use with the mosquito repellent benefit for people enrolled in Medicaid (both traditional and managed care) and CHIP. Pharmacy staff must obtain a copy of the revised standing order, effective May 1, because of the change in prescribing authority of the standing order. The previous standing order expires Apr. 30. Pharmacies may request a copy of the standing order by emailing vdp-formulary@hhsc.state.tx.us.

• Pharmacies or pharmacists not operating under the standing order will require a prescription from a valid healthcare provider prior to dispensing mosquito repellent to people enrolled in Medicaid or CHIP.
• People enrolled in in the Children with Special Health Care Needs Services Program will always require a prescription for mosquito repellent from a health care provider.
• People enrolled in the Healthy Texas Women program do not require a prescription.

Neonatal Emergency Billing Address Requirements

In accordance with House Bill (HB) 15 (83R) and HB 3433 (84R), HHSC established rules for inpatient hospital designations for neonatal services and maternal services. Hospitals without designation will not be reimbursed for inpatient neonatal or maternal services except emergency services required to be provided or reimbursed under state or federal law. The level of care designation for each hospital will be reviewed by HHSC every three years and updated as appropriate.

Action: Providers who submit claims for inpatient newborn care must use the billing address that matches the facility address of the neonatal designation where neonatal services are rendered. To be considered for reimbursement of neonatal claims, providers must have their neonatal billing address. Business edits will set on encounters where the provider is billing incorrectly.

January 1: Peer Specialist

Background: This policy is a result of House Bill (H.B.) 1486, 85th Legislature, Regular Session, 2017, which requires HHSC to establish a Medicaid reimbursable peer service benefit and adopt rules establishing training and certification requirements for peer specialists to provide Medicaid-reimbursable peer specialist "services to persons with mental illness or services to persons

The attached Peer Specialist notification outlines the new benefit, requirements for eligibility and service delivery, as well as claims filing/reimbursement details effective Jan. 1, 2019.

January 1: Morphine Equivalent Dose Limitations for RightCare to Decrease in January

RightCare from Scott and White Health Plan will decrease the daily morphine equivalent dose limit for people enrolled in Medicaid Managed Care on January 1, 2019. The new limit will be set at 90, and apply to all opioid prescriptions with exceptions for those people diagnosed with cancer or those receiving palliative or hospice care. Prescribing providers and pharmacies should contact the Navitus Provider Hotline 1-877-908-6023 for dosage limitation override assistance.

SUD Policy

Background: The attached SUD Policy notification outlines the finalized Substance Use Disorder Services policy update to be effective Jan. 1, 2019.

This policy update includes:

Updated statement of benefits section
Addressed Mental Health Parity and Addiction Equity Act requirements by allowing limits to be exceeded for adults with prior authorization
Made Medication Assisted Treatment payable on same day as withdrawal management and treatment services
Made Vivitrol payable to Chemical Dependency Treatment Facilities
Made buprenorphine payable to Physician Assistants and Nurse Practitioners as allowed under the Comprehensive Addiction and Recovery Act of 2016
Updated Prior Authorization forms for Fee for Service Medicaid recipients: Qualified Credentialed Counselor signature now permissible consistently across all forms, and supporting documentation now required with all forms consistently.

Continuing Education Credit: Immunization

Click here.

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, click here 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 11/01/2019. For more information please click here.

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. All clinical edit criteria can be found here.

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

For more information please click here.

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