Prior Authorization Criteria for Uplizna

Date: January 19, 2021 Attention: All Providers Effective Date: January 1, 2021Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Texas Children’s Health Plan would like to inform network providers that the Health and Human Services Commission (HHSC) has added Texas Medicaid and CHIP prior authorization criteria for Uplizna (procedure code J1823). Clinical policy and prior authorization requirements are found here. Uplizna is a benefit for individuals diagnosed with neuromyelitis optica spectrum disorder (NMOS/NMOSD). Uplizna must be prescribed by or in consultation with a neurologist. An initial prior authorization request for Uplizna (inebilizumab-cdon) must include the following documentation to support medical necessity:

• 18 years of age or older
• Diagnosis of neuromyelitis optica spectrum disorder (G36.0)
• Anti-aquaporin 4 (AQP4) antibody seropositive
• Screening for hepatitis B virus (HBV), quantitative serum immunoglobulins, and tuberculosis (TB) before treatment initiation
• At least one attack requiring rescue therapy in the last year or two attacks requiring rescue therapy in the previous 2 years

How this impacts providers: Uplizna must not be used concomitantly with the following therapies:

• Anti-CD20 monoclonal antibody treatments
• Complement inhibitors (e.g. Eculizumab, Ravulizumab)
• Immunosuppressant drugs (e.g. Cyclosporine, Methotrexate)
• Satralizumab

Approval for renewal or continuation therapy must include the following requirements:

• Continues to meet the following initial approval criteria
• Experiences positive clinical response to therapy as demonstrated by decreased attacks or disease stabilization
• Previously received Uplizna treatment without complications

Resource: Refer to the Outpatient Drug Services Handbook Chapter of the Texas Medicaid Provider Procedure Manual for more details on the clinical policy and prior authorization requirements. Next steps for providers: Providers should share this communication with their staff. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.