Texas: Hormone drug prior authorization and clinical criteria updates
Affects UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR Kids and STAR+PLUS plans
Effective March 1, 2024, we are updating prior authorization and clinical criteria requirements for some hormone drugs. These changes affect UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR Kids and STAR+PLUS plans. These changes align with the latest Texas Health and Human Services Commission (HHSC) criteria.
Clinical criteria requirement updates
Starting March 1, some hormone drugs, when used for certain diagnosis codes, will no longer be a covered benefit for members enrolled in UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR Kids and STAR+PLUS plans.
Affected outpatient clinician-administered drugs
The table below outlines the clinician-administered drugs impacted by these changes. Refer to the Hormonal Therapy Agents section of the Outpatient Drug Handbook of the Texas Medicaid Provider Procedure Manual for more information.
| Code | Drugs |
|---|---|
| J1000 | DEPO®-Estradiol Injectable up to 5 mg |
| J1071 | testosterone cypionate Injectable, 1 mg |
| J1380 | estradiol valerate Injectable up to 10 mg |
| J1950 | XLUPRON DEPOT®-PED (leuprolide acetate) Injectable per 3.75 mg |
| J1951 | Fensolvi® (leuprolide acetate) Injectable per 0.25 mg |
| J3121 | testosterone enanthate Injectable of 1 mg |
| J3145 | Aveed® (testosterone undecanoate) Injectable of 1 mg |
| J3315 | Trelstar® (triptorelin pamoate) Injectable of 3.75 mg |
| J3316 | Triptodur® (triptorelin, extended-release) Injectable 3.75 mg |
| J9155 | Firmagon® (degarelix) Injectable 1 mg |
| J9217 | Eligard®/Lupron Depot (leuprolide acetate) Injectable 7.5 mg |
| J9218 | leuprolide acetate Injectable 1 mg |
| J9226 | Supprelin LA®(histrelin implant) 50 mg |
| S0189 | Testopel™ (testosterone pellets) 75 mg |
Claims will be denied when hormone therapy is billed with any of the following ICD-10/diagnosis codes:
- F64.0 – Transsexualism
- F64.1 – Dual role transvestism
- F64.2 – Gender identity disorder of childhood
- F64.8 – Other gender identity disorders
- F64.9 – Gender identity disorder, unspecified
Pharmacy
Additionally, effective March 1, 2024, HHSC will require clinical prior authorization for the medications listed under the table titled “Drugs Requiring Prior Authorization” in the Texas Prior Authorization Program Clinical Criteria for Hormonal Therapy Agents.
Reference the table titled “Drugs Requiring Prior Authorization” for a full list of affected medications.
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PCA-1-23-04118-Clinical-NN_01022024
