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Updated Prior Authorization Requirements for Treatment of hATTR Effective November 1, 2026

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Effective for dates of service on or after November 1, 2026, prior authorization requirements will change for the treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis (hATTR).

Requests for Initial Therapy

Prior Authorization Required for Eplontersen (Wainua)

Prior authorization will be required for eplontersen (Wainua) (procedure code C9311), which is an antisense oligonucleotide.

Providers must submit prior authorization requests for eplontersen (Wainua) on the Special Medical Prior Authorization (SMPA) Request Form. Prior authorization requests may be approved for one 12-month duration per request.

Texas Medicaid may approve initial injection therapy for eplontersen (Wainua) if all the following criteria are met:

  • The client is 18 years of age or older.
  • The client has a diagnosis of hATTR (diagnosis code E851), supported by the following:
    • A transthyretin (TTR) mutation proven by genetic testing
    • Clinical signs and symptoms of the disease (e.g., peripheral/autonomic neuropathy, motor disability)
  • The client will not receive eplontersen (Wainua) therapy in combination with other polyneuropathy hATTR therapies (e.g., inotersen, patisiran, vutrisiran, or tafamidis meglumine).
  • The client will receive vitamin A supplementation at the recommended daily allowance while on eplontersen (Wainua) therapy.

Updated Criteria for Patisiran (Onpattro) and Vutrisiran (Amvuttra)

Texas Medicaid will update the following prior authorization requirement for patisiran (Onpattro) to include eplontersen:

  • The client will not receive patisiran (Onpattro) therapy in combination with other polyneuropathy hATTR therapies (e.g., eplontersen, inotersen, tafamidis meglumine, or vutrisiran).

Texas Medicaid will update the following prior authorization requirement for vutrisiran (Amvuttra) to include eplontersen:

  • The client will not receive vutrisiran (Amvuttra) therapy in combination with other polyneuropathy hATTR therapies (e.g., eplontersen, inotersen, tafamidis meglumine, or patisiran).

Requests for Renewal or Continuation of Therapy

For renewal or continuation of therapy with eplontersen (Wainua), patisiran (Onpattro), or vutrisiran (Amvuttra) injection, the client must meet the following requirements:

  • The client has previously received treatment with eplontersen (Wainua), patisiran (Onpattro), or vutrisiran (Amvuttra) without an adverse reaction.
  • The client has a positive clinical response to eplontersen (Wainua), patisiran (Onpattro), or vutrisiran (Amvuttra) (e.g., improved neurologic impairment, improved motor function, or slowing of disease progression).

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.