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Updated Prior Authorization Criteria for Delandistrogene Moxeparvovec-rokl (Elevidys) Effective September 1, 2024

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after September 1, 2024, Texas Medicaid will update the prior authorization criteria for delandistrogene moxeparvovec-rokl (Elevidys) as follows:

  • The age requirement for clients will change to four years of age or older.
  • Documentation that the client is ambulatory and does not use a wheelchair will no longer be required. Clients may be ambulatory or nonambulatory.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.33.1, “Prior Authorization Requirements,” for additional prior authorization criteria.

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