Antifibrinolytic agents (tranexamic acid) prior authorization
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Outpatient pharmacy prior authorization criteria for tranexamic acid (tablet and injection) under Georgia Medicaid Fee-for-Service; includes coverage conditions, exceptions, and administrative guidance for providers. Applies to outpatient pharmacy claims; office/clinic administration must be billed through physician services.
No material clinical or coverage changes in this revision.
Coverage Criteria for Tranexamic Acid
Tranexamic Acid Injection - Approvable Indication
Covered when ALL of the following are met
Approval applies to outpatient pharmacy administration; injection must be administered in the member's home or in a long-term care facility.
Medications that are administered in a physician's office or clinic are excluded from outpatient pharmacy coverage and must be billed through the physician services program. Providers should not submit claims for in-office or in-clinic administration of medication to the outpatient pharmacy benefit; information about the DCH physician services program is available at www.mmis.georgia.gov.
Provider Requirements and Administrative Guidance
Prior authorization required for injection (hemophilia indication)
Tranexamic acid injection dispensed through the outpatient pharmacy requires prior authorization; approvals are limited to members with a diagnosis of hemophilia to reduce or prevent hemorrhage and to reduce the need for replacement therapy during and following tooth extraction. Authorization applies when the injection is administered in the member’s home or a long-term care facility as specified in the PA criteria.
- Approval indication: hemophilia to reduce/prevent hemorrhage and reduce replacement therapy during/after tooth extraction
- Administration setting required for approval: member's home or long-term care facility
Preferred product guidance — tablet preferred, injection non‑preferred
Use the tablet formulation (generic tranexamic acid) as the preferred product when clinically appropriate; the injection formulation is listed as non‑preferred in the PA summary.
- Preferred: tranexamic acid tablet (generic)
- Non‑Preferred: tranexamic acid injection (generic)
PA submission and documentation — follow DCH/OptumRx process
Initiate prior authorization and submit required documentation through the DCH PA process; providers may begin the PA process by calling OptumRx at 1‑866‑525‑5827 and can access the PA Request Process Guide online for required documentation and submission instructions.
- To initiate PA by phone: OptumRx 1‑866‑525‑5827
- Online PA process and documentation: https://www.dch.georgia.gov/priorauthorization-process-and-criteria (see PA Request Process Guide)
Site‑of‑care billing — bill office/clinic administrations to physician services
Do not bill medications administered in a physician’s office or clinic through the outpatient pharmacy program; such medications must be billed to the physician services program and may be denied if submitted to outpatient pharmacy.
- Medications given in physician office/clinic must be billed through DCH physician services program (see www.mmis.georgia.gov)
- Claims billed to outpatient pharmacy instead of physician services may be denied
Site-of-Care Restrictions and Administration
Home or long‑term care administration required
For approvals described in this policy, tranexamic acid injection must be administered in the member's home or in a long‑term care facility; injections given in a physician office/clinic are not covered under the outpatient pharmacy program.
Definitions and Billing Notes
Step Therapy and Product Preference
| Step | Requirement |
|---|---|
| 1 | Tablet formulation is preferred; injection is non-preferred — use the preferred tranexamic acid tablet when appropriate before using tranexamic acid injection. |
Quantity Limits
Background
Tranexamic acid is an antifibrinolytic agent used to reduce bleeding risk in patients with bleeding disorders such as hemophilia, including peri‑ and post‑procedural settings (for example, dental extractions). The policy addresses outpatient pharmacy prior authorization and coverage conditions for tranexamic acid formulations and notes differences in preferred status between tablet and injection formulations.
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