Updated Prior Authorization Criteria for Monoclonal Antibodies Effective April 1, 2026
AI Summary
Texas Medicaid is updating prior authorization criteria for two monoclonal antibody therapies effective April 1, 2026. Mepolizumab will now be covered for COPD treatment with specific eosinophilic and exacerbation requirements, while tezepelumab-ekko will be covered for chronic rhinosinusitis with nasal polyps. Both require detailed clinical documentation and prior authorization approval.
Action Required
Before April 1, 2026: Billing team must update prior authorization workflows for mepolizumab (COPD treatment) and tezepelumab-ekko (chronic rhinosinusitis with nasal polyps) in Texas Medicaid. Create documentation checklists requiring age verification, specific diagnosis codes, triple therapy failure evidence, exacerbation history, and eosinophil levels for mepolizumab. Update encounter forms to capture required clinical criteria. Contact TMHP at 800-925-9126 for questions. Claims without proper prior authorization will be denied.
Affected Billing Codes
Plan Types
Medicaid
States
TX
Specialties
pulmonology, ent, allergy-immunology