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05/21/2026
Medical Policy Medical Necessity Determination and Appeal Overturn Policy for Off-Label Use of Farxiga® (dapagliflozin) in Pediatric members with Heart Failure and Complex Cardiac Conditions Publication- 5/26/2026 Effective Date-6/26/2026 PURPOSE: The purpose of this policy is to establish clinical criteria and an evidence-based framework for reviewing appeals requesting coverage of off-label use of Farxiga® (dapagliflozin) in pediatric members (<18 years of age) diagnosed with heart failure (HF) and ...
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05/21/2026
Medical Policy Medical Necessity Determination and Appeal Overturn Policy for Off-Label Inhaled Tobramycin® Use in Pediatric members <6 Years of Age with Cystic Fibrosis Publication- 5/26/2026 Effective Date-6/26/2026 PURPOSE: To define medical necessity criteria for overturn of an appeal of off-label use of inhaled tobramycin in pediatric members under six (6) years of age with documented or suspected Pseudomonas aeruginosa infection in the setting of cystic fibrosis (CF). Although FDA labeling for n...
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05/05/2026
Medical Policy and Prior Authorization Notice Biosimilar Utilization Management Strategy Publication Date-5/6/26 Effective Date-6/6/26 PURPOSE: The purpose of this medical policy is to establish a biosimilar-first utilization management strategy for clinician administered drugs (CADs) administered under the medical benefit and reimbursed via NDC- HCPCS crosswalk at Parkland Community Health Plan (PCHP). This policy requires preferential use of FDA-approved biosimilar products over the reference product. ...
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02/06/2026
Medical Policy and Prior Authorization Notice Screening, Brief Intervention and Referral to Treatment (SBIRT) PURPOSE: The goal of this policy is to establish standards and medical necessity criteria to guide Parkland Community Health Plan (PCHP) authorization decisions for requests for Screening, Brief Intervention and Referral to Treatment (SBIRT), when prior authorization is required. SCOPE: This policy only applies to requests for SBIRT services that exceed the limitations outlined in the Texas Medic...
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02/06/2026
Medical Policy and Prior Authorization Notice Psychiatric Diagnostic Evaluations PURPOSE: The goal of this policy is to establish standards and medical necessity criteria to guide Parkland Community Health Plan (PCHP) authorization decisions for requests for Psychiatric Diagnostic Evaluations, when prior authorization is required. SCOPE: This policy only applies to requests for Psychiatric Diagnostic Evaluation services that exceed the limitations outlined in the Texas Medicaid Provider Procedures Manual...
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02/06/2026
Medical Policy and Prior Authorization Notice Rituxamab (Rituxan®) Publication- 12/1/2025 Effective Date-1/1/2026 PURPOSE: The goal of this policy is to establish standards for unapproved use (off label use) of Rituximab at Parkland Community Health Plan (PCHP) for the best possible member care, safety, and resource management. Throughout the policy, Rituximab refers to Rituximab and biosimilars as appropriate. SCOPE: This policy applies to all members of STAR and CHIP receiving Rituximab prescription as...
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02/06/2026
Medical Policy and Prior Authorization Notice Asparaginase Erwinia (recombinant)-rywn (Rylaze®) Effective Date-9/6/24 Renewal Date-12/17/25 PURPOSE: The goal of this policy is to establish standards and recommendations for the proper use of Erwinia asparaginase in the Parkland Community Health Plan for the best possible member care, safety, and resource management. SCOPE: All Parkland Community Health Plan members of STAR, and CHIP. POLICY: 1. Descriptions Asparaginase Erwinia (recombinant)-rywn (Rylaze®...