Prior Authorization Requirements for E0788 (Vyalev) Effective January 1, 2027

By January 1, 2027: Billing team and clinical staff must implement prior authorization requirements for E0788 (Vyalev) claims submitted to TMHP. (1) Update billing software to require prior authorization submission for E0788 before claim submission. (2) Clinical staff must document and verify all initiation criteria are met: advanced Parkinson's disease diagnosis, prescription by or in consultation with a neurologist, patient responsiveness to levodopa-containing therapy, presence of motor fluctuations despite optimized pharmacotherapy, and documented minimum 2.5 hours of daily "off" time (stiffness, slow movements, difficulty initiating movement, tremor, or walking difficulty). (3) For continuation of therapy, ensure documentation of established therapy and positive clinical response. (4) Contact the specific MCO for each TMHP member to confirm administrative procedures, as requirements may vary by managed care organization. (5) Retain the TMHP Contact Center number (800-925-9126) for prior authorization inquiries. Claims submitted without required prior authorization will be subject to denial.