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Prior Authorization Updates for Inebilizumab-cdon (Uplizna) Effective October 1, 2025, for Texas Medicaid

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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 the prior authorization criteria for inebilizumab-cdon (Uplizna) (procedure code J1823) to include an additional indication.

Treatment Indications

Inebilizumab-cdon (Uplizna) will also be indicated for adult clients who are 18 years of age or older with immunoglobulin G4-related disease (IgG4-RD).

Texas Medicaid may approve prior authorization of initial therapy for a 12-month duration for clients who have IgG4-RD if they meet all the following criteria:

  • The client is 18 years of age or older.
  • The client has been diagnosed with IgG4-RD (diagnosis code D8984), and other conditions that mimic IgG4-RD have been ruled out (e.g., malignancy, infection, or other autoimmune disorders).
  • The client is experiencing or has recently experienced an IgG4-RD flare that requires the initiation or continuation of glucocorticoid treatment.
  • The client has a history of IgG4-RD affecting at least two organs.

Providers can refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook, subsection 6.69, “Inebilizumab-cdon (Uplizna),” for additional indications for inebilizumab-cdon (Uplizna).

Renewal or Continuation of Therapy

To renew or continue this drug therapy for clients with neuromyelitis optica spectrum disorder or IgG4-RD, the client must have previously received inebilizumab-cdon (Uplizna) treatment without complications or unacceptable toxicity (e.g., infusion reactions or serious infections).

Providers can refer to the current TMPPM, Outpatient Drug Services Handbook, subsection 6.69.1, “Prior Authorization Criteria,” for additional requirements for renewal or continuation of therapy.

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