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Prior Authorization Criteria for Inebilizumab-cdon (Uplizna) Effective January 1, 2021

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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 January 1, 2021, prior authorization is required for inebilizumab-cdon (Uplizna) (procedure code J1823).

Inebilizumab-cdon (Uplizna) is indicated to treat adult clients with neuromyelitis optica spectrum disorder (NMOD/NMOSD) who are anti-aquaporin-4 antibody positive.

Inebilizumab-cdon (Uplizna) must be prescribed by, or in consultation with, a neurologist.

Requests for Initial Therapy

Initial therapy requests for inebilizumab-cdon (Uplizna) may be approved for a 12-month duration, if all of the following criteria are met:

  • The client must be 18 years of age or older.
  • The client has a diagnosis of neuromyelitis optica spectrum disorder (diagnosis code G360).
  • The client is anti-aquaporin 4 (AQP4) antibody seropositive.
  • The client has been screened for hepatitis B virus, quantitative serum immunoglobulins, and tuberculosis prior to initiating treatment.
  • The client had at least one attack requiring rescue therapy in the last year or two attacks requiring rescue therapy in the last 2 years.
  • The client is not receiving inebilizumab-cdon (Uplizna) concomitantly with the following therapies:
    • Anti-CD20 monoclonal antibody treatments
    • Complement inhibitors (e.g., Eculizumab, Ravulizumab)
    • Immunosuppressant drugs (e.g., Cyclosporine, Methotrexate)
    • Satralizumab

Requests for Renewal or Continuation of Therapy

For renewal or continuation therapy requests, the client must meet all of the following requirements:

  • The client continues to meet the initial approval criteria.
  • The client experienced positive clinical response to therapy as demonstrated by decreased attacks or disease stabilization.
  • The client has previously received inebilizumab-cdon (Uplizna) treatment without complications.

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