MedicaidPrior AuthMedium impact
BT2024143: IHCP announces PA criteria for physician-administered Viltepso (J1427)
Indiana Medicaid (IHCP)·IN · Neurology, Pediatrics, PM&R (Physical Medicine & Rehab)·Provider Bulletin
Effective date
Oct 17, 2024
We identified it
Jun 19, 2026
Summary
Indiana Medicaid will require prior authorization for physician-administered Viltepso (HCPCS J1427) starting October 17, 2024. This aligns medical benefit PA requirements with existing pharmacy benefit criteria for this Duchenne muscular dystrophy medication.
Action Required
By October 17, 2024: Billing team must update systems to require prior authorization for HCPCS J1427 (Viltepso injections) for all Indiana Medicaid patients. Submit PA requests to Acentra Health at 866-725-9991. Update encounter forms to remind providers that documentation of DMD diagnosis with exon 53 skipping mutation, dosing limits (80mg/kg weekly), and clinical status measurements are required. Claims without prior auth will be denied after October 17.