MedicaidPrior AuthMedium impact
Prior Authorization Required for Depemokimab-ulaa (Exdensur)
Texas Medicaid·TX · Pulmonology, Pediatrics, Allergy & Immunology·Prior Authorization
Effective date
Sep 1, 2026
We identified it
Jul 31, 2026
Summary
Effective September 1, 2026, prior authorization is now required for depemokimab-ulaa (Exdensur), a subcutaneous injection for severe eosinophilic asthma in patients 12+. The billing team must obtain SMPA approval before claims are submitted, and must ensure claims do not combine J2361 with certain other monoclonal antibody codes (J0517, J2182, J2356, J2786) on the same date of service.
Action Required
By August 31, 2026: (1) Billing team must update billing system to require prior authorization via SMPA form for procedure code J2361 effective September 1, 2026. (2) Configure system to block/prevent duplicate billing of J2361 with J0517, J2182, J2356, or J2786 on the same date of service. (3) Educate providers and front desk staff on medical necessity criteria: patient age 12+, confirmed severe asthma diagnosis (J4550, J4551, J8283), eosinophilic count ≥150 cells/microliter, uncontrolled asthma despite 3+ months of ICS therapy, and documented inadequate control (≥2 SCS exacerbations in prior year OR FEV1 <80% predicted). (4) Update encounter templates to flag that Exdensur is add-on maintenance therapy only, not monotherapy, and cannot be combined with omalizumab, benralizumab, mepolizumab, or reslizumab. (5) Communicate to providers that office visit claims cannot be submitted if the only service is monoclonal antibody injection (omalizumab, benralizumab, mepolizumab, reslizumab, or tezepelumab-ekko). Failure to obtain prior authorization before September 1, 2026 will result in claim denials.