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Updated Prior Authorization Criteria for Delandistrogene Moxeparvovec‐rokl (Elevidys) Effective November 1, 2026

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Effective for dates of service on or after November 1, 2026, Texas Medicaid will update the prior authorization criteria for delandistrogene moxeparvovec‐rokl (Elevidys). This follows the changes to the medication label that the U.S. Food & Drug Administration (FDA) recently made about how to use delandistrogene moxeparvovec‐rokl (Elevidys) (procedure code J1413) safely and effectively.

Updated Prior Authorization Requirement

Delandistrogene moxeparvovec‐rokl (Elevidys) is a one-time intravenous infusion therapy indicated for the treatment of clients with Duchenne muscular dystrophy who are 4 years of age and older and ambulatory.

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.