Skip to main content

Updated Prior Authorization Criteria for Monoclonal Antibodies Effective July 1, 2024

Last updated on

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, 2024, prior authorization criteria will be updated for monoclonal antibody therapy with omalizumab and benralizumab.

Updated Prior Authorization Requirements for Omalizumab

The U.S. Food and Drug Administration (FDA) has approved the injectable drug omalizumab for the following:

  • Clients who are 6 years of age or older who have moderate to severe persistent asthma
  • Clients who are 12 years of age or older and have chronic spontaneous urticaria (CSU) who remain symptomatic despite H1 antihistamine treatment
  • Adult clients who are 18 years of age or older with inadequate response to nasal corticosteroids as an add-on maintenance treatment of chronic rhinosinusitis with nasal polyps (CRwNP)
  • Adult and pediatric clients who are 1 year of age or older for the reduction of allergic reactions (Type I), including anaphylaxis, that may occur with accidental exposure to one or more foods
    • The client must have a diagnosis of immunoglobulin E (IgE)-medicated food allergy (diagnosis code Z91010, Z91011, Z91012, Z91013, or Z91018).
    • The client must use omalizumab in conjunction with food allergen avoidance.

Updated Prior Authorization Requirements for Benralizumab

Benralizumab is an injectable drug that is FDA-approved and indicated as an add-on maintenance treatment for clients who are 6 years of age or older and have severe asthma with an eosinophilic phenotype.

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