MedicaidPrior AuthMedium impact
Prior Authorization Criteria and Age Limitation Updates for CAD Enzyme Replacement Therapy Effective October 1, 2026
Texas Medicaid·TX · Genetics, Pediatrics, Internal Medicine·Prior Authorization
Effective date
Oct 1, 2026
We identified it
Sep 30, 2026
Summary
Effective October 1, 2026, Texas Medicaid is implementing new prior authorization requirements for two enzyme replacement therapy drugs (tividenofusp alfa-eknm/Avlayah and pegzilarginase-nbln/Loargys) and updating age limitations for three additional rare disease treatments (galsulfase, imiglucerase, and taliglucerase alfa). All prior authorization requests must be submitted using the Special Medical Prior Authorization (SMPA) Request Form.
Action Required
By September 30, 2026: Billing and clinical teams must (1) update billing system rules to require prior authorization for HCPCS codes J1757 and J1818 effective October 1, 2026; (2) obtain the Special Medical Prior Authorization (SMPA) Request Form from TMHP and establish process for submitting all tividenofusp alfa-eknm and pegzilarginase-nbln requests; (3) verify patient age and diagnosis criteria before claim submission—tividenofusp alfa-eknm requires patient weight ≥5kg with MPS II diagnosis (E761), and pegzilarginase-nbln requires patient age ≥2 years with ARG1-D diagnosis (E7221) plus concurrent dietary protein restriction; (4) update encounter forms and provider alerts to flag these drugs as requiring prior authorization; (5) verify age eligibility for galsulfase (≥5 years), imiglucerase (all ages), and taliglucerase alfa (≥4 years) claims. Contact TMHP at 800-925-9126 for form access. Claims submitted without prior authorization will be denied. Note: Managed care organizations (MCOs) may have different administrative procedures—confirm specific prior auth process with member's MCO.