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Prior Authorization Updates for Antisense Oligonucleotides Effective July 1, 2025

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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 July 1, 2025, prior authorization criteria will change as follows for antisense oligonucleotides:

  • The Texas Medicaid & Healthcare Partnership (TMHP) may consider prior authorization for procedure codes J1426, J1427, J1428, and J1429 with diagnosis code G7101.
  • TMHP may consider prior authorization for procedure code J2326 with diagnosis codes G120, G121, G128, and G129.
  • TMHP may consider prior authorization for procedure code J1304 with diagnosis code G1221.

Providers can refer to the Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.11.1, “Prior Authorization Requirements,” for the additional documentation requirements.

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