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Prior Authorization Criteria for Onasemnogene Abeparvovec-xioi (Zolgensma) to Change for Texas Medicaid December 1, 2020

Last updated on 10/16/2020

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after December 1, 2020, prior authorization criteria for onasemnogene abeparvovec-xioi (Zolgensma) will change for Texas Medicaid.

The documentation requirement for confirming a diagnosis of Type I spinal muscular atrophy (SMA) will change to the following:

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after December 1, 2020, prior authorization criteria for onasemnogene abeparvovec-xioi (Zolgensma) will change for Texas Medicaid.

The documentation requirement for confirming a diagnosis of Type I spinal muscular atrophy (SMA) will change to the following:

Confirmed diagnosis of Type I SMA (diagnosis code G120) based on gene mutation analysis with biallelic survival motor neuron 1 (SMN1) mutation (deletion or point mutation) and 3 or less copies of SMN2.

Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.57.2, “Documentation Requirements,” for additional prior authorization criteria.

For more information, call the TMHP Contact Center at 800-925-9126.