Exondys 51™ (eteplirsen) - C9484
Effective April 1, 2017, the following procedure code was added as a Texas Medicaid benefit.
C9484* (See prior authorization details below)
* C9484 is pending approval of expenditures by the Legislative Budget Board (LBB).
The procedure code listed in the table above will be added as a Medicaid benefit as of the Centers for Medicare & Medicaid Services (CMS) effective date, April 1, 2017.
The procedure code will be payable at the April 1, 2017, published rate until the HHSC rate hearing is held, as required by 1 Texas Administrative Code §355.201.
New benefits that are adopted by Texas Medicaid must complete the rate hearing process to receive public comment on proposed Texas Medicaid reimbursement rates.
Providers will be notified in a future banner message or web article if a proposed reimbursement rate change or if a procedure code will not be reimbursed because the expenditures are not approved.
For more information about the process for clinician administered drugs, providers may refer to the article titled, “Clinician Administered (Physician Administered) Drug Procedure Codes Added During Quarterly HCPCS Updates May Be Payable According to the CMS Effective Date,” which was published on this website on September 15, 2016.
Providers may also refer to the following for public notifications with details related to rate hearings:
Fee-for-Service Prior Authorization for Procedure Code C9484
Procedure code C9484 will require prior authorization for Texas Medicaid fee-for-service.
Requests for prior authorization for procedure code C9484 must be submitted by the provider to the Special Medical Prior Authorization (SMPA) department at TMHP using the Special Medical Prior Authorization (SMPA) Request Form.
All prior authorization requests for procedure code C9484 will be considered after review by the medical director. All questions should be directed to your Health Plan Management team.