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January 18, 2024

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.

Questions? We're here to help

Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal. For additional contact information, visit our Contact us page.

PCA-1-23-04118-Clinical-NN_01022024

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