Updated Prior Authorization Requirements for Treatment of hATTR Effective November 1, 2026

By November 1, 2026: Billing and prior authorization teams must implement the following changes in the billing system and prior authorization workflows: (1) Configure procedure code C9311 (eplontersen/Wainua) to require prior authorization submission on the SMPA Request Form for Texas Medicaid; (2) Update prior authorization logic to enforce one 12-month approval duration per eplontersen request; (3) Implement screening criteria in the authorization system to verify client age (≥18 years), hATTR diagnosis (E851) with TTR mutation confirmation and clinical symptoms, vitamin A supplementation plan, and non-duplication against inotersen, patisiran, vutrisiran, and tafamidis meglumine; (4) Add eplontersen to existing non-duplication criteria for patisiran (Onpattro) and vutrisiran (Amvuttra) authorization checks; (5) For renewal requests, configure the system to verify prior treatment without adverse reaction and documented positive clinical response (neurologic improvement, motor function improvement, or disease progression slowing). Failure to implement prior authorization will result in claim denials. Contact TMHP Contact Center (800-925-9126) for clarification or MCO-specific administrative procedures.