Prior Authorization Criteria Updated for Uplizna to Include Generalized Myasthenia Gravis

Date: August 31, 2026

Attention: All Providers

Effective date: November 1, 2026

Call to action: Texas Children's Health Plan (TCHP) would like to inform providers that effective for dates of service on or after November 1, 2026, Texas Medicaid will update prior authorization criteria for inebilizumab-cdon (Uplizna) (procedure code J1823) to include generalized myasthenia gravis (gMG).

Prior Authorization Requirements

The U.S. Food & Drug Administration (FDA) has approved gMG as an indication in adult patients who are anti-acetylcholine receptor (AChR) or anti-muscle-specific tyrosine kinase (MuSK) antibody positive.

The Texas Medicaid & Healthcare Partnership (TMHP) will consider prior authorization requests for gMG for a 12-month duration when the patient meets the following criteria:

• The patient is 18 years of age or older.
• The patient has a diagnosis of gMG, Myasthenia Gravis Foundation of America (MGFA) clinical classification of II, III, or IV (diagnosis codes G7000 and G7001).
• The patient is anti-AChR or anti-MuSK antibody positive.
• The patient’s Myasthenia Gravis-Activities of Daily Living (MG-ADL) score is between six and ten.
• The patient has a Quantitative Myasthenia Gravis (QMG) score greater than 11.
• The patient is on a stable dose of corticosteroid, a specific non-steroidal immunosuppressive therapy, or a combination of both.
• The patient is not receiving inebilizumab-cdon (Uplizna) to treat myasthenia gravis concomitantly with the following therapies:
  • Anti-CD20 monoclonal antibody treatments
  • Complement inhibitors (such as ravulizumab-cwvz [Ultomiris] or zilucoplan [Zilbrysq])
  • A neonatal Fc receptor (FcRn) blocker (such as nipocalimab-aahu [Imaavy], rozanolixizumab-noli [Rystiggo], efgartigimod alfa-fcab [Vyvgart], or efgartigimod alfa and hyaluronidase-qvfc [Vygart Hytrulo])

Next step for providers: Providers should share this information with their staff.

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

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