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Texas Medicaid Prior Authorization Criteria for Emapalumab-Lzsg (Gamifant) Will Change on 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, providers must meet updated prior authorization requirements for emapalumab-lzsg (Gamifant) (procedure code J9210).

Emapalumab-lzsg (Gamifant) is an interferon gamma (IFNy)-blocking antibody that is indicated for the treatment of the following:

  • Primary hemophagocytic lymphohistiocytosis (HLH) in clients who have refractory, recurrent, or progressive disease or intolerance of conventional HLH therapy
  • HLH or macrophage activation syndrome (MAS) in clients who have known or suspected Still’s disease (including systemic juvenile idiopathic arthritis [sJIA]) and an inadequate response to or intolerance of glucocorticoids or recurrent MAS

Authorization Requirements

Texas Medicaid will approve prior authorization requests for up to six months of initial therapy if the client has one of the diagnoses listed below:

  • Primary HLH (diagnosis code D761), diagnosed based on one of the following:
    • Genetic mutation of the gene known to cause primary HLH (e.g., PRF1, UNC13D, STX11, or STXBP2) or a family history consistent with primary HLH
    • Confirmation of at least five of the following criteria:
      • Fever ≥ 101.3 °F
      • Splenomegaly
      • Cytopenia defined by at least two of the following: Hemoglobin < 9 g/dl, platelet count < 100 x 109 /L, or neutrophils < 1 x 109
      • Fasting triglycerides > 265 mg/dl or fibrinogen ≤ 1.5 g/L
      • Hemophagocytosis in the liver, bone marrow, spleen, or lymph node
      • Low or absent natural killer (NK) cell activity
      • Serum ferritin concentration ≥ 500 mg/L
      • High plasma concentration of soluble CD25 (i.e., soluble interleukin-2 receptor) > 2,400 U/mL
  • HLH or MAS in Still’s disease, diagnosed based on the following:
    • A diagnosis of HLH along with a confirmed or suspected diagnosis of systemic juvenile idiopathic arthritis or adult onset of Still’s disease
    • A diagnosis of active MAS with ferritin level greater than 684 ng/mL and any of two of the four laboratory criteria listed below:
      • Platelet count ≤ 181 x 109/L
      • Aspartate aminotransferase (AST) > 48 U/L
      • Triglycerides > 156 mg/dL
      • Fibrinogen levels ≤ 360 mg/dL
  • An inadequate response to high-dose IV glucocorticoids
  • No active infections caused by specific pathogens favored by IFNy neutralizations (such as mycobacteria and Histoplasma capsulatum).

Providers must submit prior authorization requests for procedure code J9210 with one or more of the following diagnosis codes:

Diagnosis Codes
D761M061M0820M08211M08212M08219M08221
M08222M08229M08231M08232M08239M08241M08242
M08249M08251M08252M08259M08261M08262M08269
M08271M08272M08279M0828M0829  

Renewal or Continuation Therapy

Prior authorization requests for renewal or continuation therapy with emapalumab-lzsg (Gamifant) must include documentation that the client:

  • Continues to meet the initial approval criteria.
  • Continues to require emapalumab-lzsg (Gamifant) as HLA treatment.

Texas Medicaid will not approve prior authorization for renewal or continuation therapy after the initiation of hematopoietic stem cell transplant (HSCT) or if the treatment for HLH or MAS becomes unnecessary.

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