Prior Authorization Updates for Antisense Oligonucleotides Effective July 1, 2025

Date: June 9, 2025

Attention: All Providers

Prior authorization effective date: July 1, 2025

Call to action: The purpose of this communication is to inform providers that effective for dates of service on or after July 1, 2025, prior authorization criteria will change as follows for antisense oligonucleotides:

• The Texas Medicaid & Healthcare Partnership (TMHP) may consider prior authorization for procedure codes J1426, J1427, J1428, and J1429 with diagnosis code G7101.
• TMHP may consider prior authorization for procedure code J2326 with diagnosis codes G120, G121, G128, and G129.
• TMHP may consider prior authorization for procedure code J1304 with diagnosis code G1221.

Next step for providers: Providers should refer to the Texas Medicaid Provider Procedures Manual (TMPPM),Outpatient Drug Services Handbook, subsection 6.11.1, “Prior Authorization Requirements,” for the additional documentation requirements

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts,log into:
www.texaschildrenshealthplan.org/provideralerts.