MedicaidPrior AuthMedium impact
Updated Prior Authorization Criteria for Teplizumab-mzwv (Tzield)
Texas Medicaid·TX · Endocrinology, Pediatrics·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Sep 3, 2026
Summary
Texas Medicaid updated prior authorization criteria for teplizumab-mzwv (Tzield) effective October 1, 2026. The policy now covers treatment for pediatric patients ages 8-17 with recently diagnosed stage 3 type 1 diabetes (in addition to existing stage 2 coverage for ages 1+). Prior authorization requires documentation of stage 3 T1D diagnosis with at least one positive pancreatic islet cell antibody and confirmation of residual beta cell function via C-peptide testing.
Action Required
By September 30, 2026: Billing and clinical teams must update prior authorization workflows to reflect the new stage 3 T1D coverage criteria. (1) Update billing system and prior authorization templates to distinguish between stage 2 T1D (ages 1+) and stage 3 T1D (ages 8-17 only) indications. (2) Create checklist for billing team to verify required documentation before submitting prior authorization requests: confirmed stage 3 T1D diagnosis, at least one positive pancreatic islet cell antibody (ICA, IA-2A, IAA, ZnT8A, or GAD), and C-peptide level >0.2 pmol/mL from MMTT or alternative method. (3) Train front-desk and billing staff on new eligibility requirements to prevent claim denials. (4) For MCO-enrolled Medicaid members, contact the specific MCO for plan-specific prior authorization procedures, as requirements may differ from traditional Medicaid. Contact TMHP at 800-925-9126 with questions. Claims submitted without proper prior authorization documentation will be denied.