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Updated Prior Authorization Criteria for Monoclonal Antibodies Effective April 1, 2026

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Effective for dates of service on or after April 1, 2026, Texas Medicaid will update the prior authorization criteria for monoclonal antibody therapy using mepolizumab and tezepelumab-ekko.

Updated Prior Authorization Requirements for Mepolizumab

The U.S. Food & Drug Administration (FDA) has approved the injectable drug mepolizumab as an add-on maintenance treatment for inadequately controlled chronic obstructive pulmonary disease (COPD) with an eosinophilic phenotype.

The Texas Medicaid & Healthcare Partnership (TMHP) will consider prior authorization for mepolizumab to treat COPD when the following criteria are met:

  • The client is 18 years of age or older.
  • The client has a diagnosis of inadequately controlled COPD (diagnosis code J440, J441, J4489, or J449), confirmed by either spirometry or classic signs and symptoms.
  • The client’s COPD is uncontrolled despite treatment with triple therapy, which includes an inhaled corticosteroid (ICS), long-acting beta agonist (LABA), and long-acting muscarinic antagonist (LAMA).
  • The client’s inadequately controlled COPD is demonstrated by one or both of the following within the previous year:
    • At least two moderate exacerbations despite treatment with triple inhaled therapy
    • One or more severe exacerbations despite treatment with triple inhaled therapy
  • The client has an eosinophilic phenotype defined by a baseline blood eosinophil level of at least ≥ 150 cells per microliter before treatment with mepolizumab.

Mepolizumab will be used as an add-on maintenance therapy and not as the primary treatment for COPD.

Updated Prior Authorization Requirements for Tezepelumab-ekko

The FDA has approved the injectable drug tezepelumab-ekko as an add-on treatment for chronic rhinosinusitis with nasal polyps (CRSwNP).

TMHP will consider prior authorization for tezepelumab-ekko to treat CRSwNP when the following criteria are met:

  • The client is 12 years of age or older.
  • The client has a confirmed diagnosis of CRSwNP (diagnosis code J330, J331, J338, or J339).

Tezepelumab-ekko will be used as an add-on maintenance therapy and not as a single or primary therapy.

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

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.