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Updated Prior Authorization Criteria for Enzyme Replacement Therapy Olipudase Alfa-Rpcp (Xenpozyme) Effective October 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 October 1, 2025, Texas Medicaid will update prior authorization criteria for enzyme replacement therapy olipudase alfa-rpcp (Xenpozyme).

In addition to diagnosis codes E75241 and E75244, Texas Medicaid will also consider E75240, E75248, and E75249 for prior authorization.

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook, subsection 6.45, “Enzyme Replacement Therapy (ERT),” for more information about prior authorization criteria.

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