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Prior Authorization Criteria Updated for Inebilizumab-cdon (Uplizna) to Include Generalized Myasthenia Gravis

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Effective for dates of service on or after November 1, 2026, Texas Medicaid will update prior authorization criteria for inebilizumab-cdon (Uplizna) (procedure code J1823) to include generalized myasthenia gravis (gMG).

Prior Authorization Requirements

The U.S. Food & Drug Administration (FDA) has approved gMG as an indication in adult clients who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive.

The Texas Medicaid & Healthcare Partnership (TMHP) will consider prior authorization requests for gMG for a 12-month duration when the client meets the following criteria:

  • The client is 18 years of age or older.
  • The client has a diagnosis of gMG, Myasthenia Gravis Foundation of America (MGFA) clinical classification of II, III, or IV (diagnosis codes G7000 and G7001).
  • The client is anti-AChR or anti-MuSK antibody positive.
  • The client’s Myasthenia Gravis-Activities of Daily Living (MG-ADL) score is between six and ten.
  • The client has a Quantitative Myasthenia Gravis (QMG) score greater than 11.
  • The client is on a stable dose of corticosteroid, a specific non-steroidal immunosuppressive therapy, or a combination of both.
  • The client is not receiving inebilizumab-cdon (Uplizna) to treat myasthenia gravis concomitantly with the following therapies:
    • Anti-CD20 monoclonal antibody treatments
    • Complement inhibitors (such as ravulizumab-cwvz [Ultomiris] or zilucoplan [Zilbrysq])
    • A neonatal Fc receptor (FcRn) blocker (such as nipocalimab-aahu [Imaavy], rozanolixizumab-noli [Rystiggo], efgartigimod alfa-fcab [Vyvgart], or efgartigimod alfa and hyaluronidase-qvfc [Vygart Hytrulo])

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.