MedicaidPrior AuthMedium impact
Prior Authorization Criteria Updated for Inebilizumab-cdon (Uplizna) to Include Generalized Myasthenia Gravis
Texas Medicaid·TX · Neurology, Internal Medicine·Prior Authorization
Effective date
Nov 1, 2026
We identified it
Aug 28, 2026
Summary
Texas Medicaid is expanding prior authorization criteria for inebilizumab-cdon (Uplizna, J1823) to now include generalized myasthenia gravis (gMG) in adult patients meeting specific clinical and serological criteria, effective November 1, 2026. Billing teams must implement prior authorization requirements for this indication and ensure claims include proper diagnostic codes (G7000, G7001) and verification of antibody positivity and clinical scores.
Action Required
By October 15, 2026: Billing team must update prior authorization protocols in billing system to require prior auth for HCPCS code J1823 (inebilizumab-cdon/Uplizna) when billed with ICD-10 diagnosis codes G7000 or G7001 for Texas Medicaid claims. Prior to November 1, 2026: Train billing staff and providers on new gMG indication criteria, including required documentation elements: patient age verification (18+), MGFA clinical classification (II, III, or IV), anti-AChR or anti-MuSK antibody status, MG-ADL score (6-10), QMG score (>11), and stable corticosteroid or immunosuppressive therapy. Update encounter templates to capture these clinical parameters. Add system rules to flag and reject claims missing these documentation elements or containing concomitant use of anti-CD20 agents, complement inhibitors, or FcRn blockers. Contact Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 for MCO-specific prior authorization procedures as requirements may vary by MCO. Failure to obtain prior authorization or submit complete clinical documentation will result in claim denials.