Prior Authorization Criteria for Zopapogene Imadenovec-drba (Papzimeos) Effective May 1, 2026
AI Summary
Starting May 1, 2026, Texas Medicaid will require prior authorization for zopapogene imadenovec-drba (Papzimeos) using procedure code J3404. This drug treats adults with recurrent respiratory papillomatosis and requires specific criteria including age 18+, confirmed diagnosis, HPV serotype documentation, and surgical debulking before treatment.
Action Required
By May 1, 2026: Billing team must update system to require prior authorization for HCPCS code J3404 (zopapogene imadenovec-drba) for Texas Medicaid patients. Providers must use Special Medical Prior Authorization (SMPA) Request Form and ensure all criteria are met including patient age 18+, diagnosis code D141, HPV serotype documentation, and surgical debulking attestation. Claims will be denied without proper prior authorization.
Affected Billing Codes
Plan Types
Medicaid
States
TX
Specialties
ent, pulmonology, oncology