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Updated Prior Authorization Criteria for Delandistrogene Moxeparvovec-rokl (Elevidys) Effective April 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 April 1, 2024, prior authorization criteria for delandistrogene moxeparvovec-rokl (Elevidys), procedure code J1413, will be updated.

Prior authorization criteria that required a client to have a confirmed gene mutation in the Duchenne muscular dystrophy (DMD) gene between exons 18 to 58 will be updated.

The updated prior authorization criteria will require a client to have a confirmed mutation in the DMD gene and prescribers should monitor clients with a mutation in exons 1-17 and/or 59-71 of the DMD gene for immune-medicated myositis.

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