Date: September 30, 2025
Attention: All Providers
Subject: Prior Authorization Updates for Inebilizumab-cdon (Uplizna)
Effective date: October 1, 2025
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after October 1, 2025, Texas Medicaid will update the prior authorization criteria for inebilizumab-cdon (Uplizna) (procedure code J1823) to include an additional indication.
Treatment Indications
Inebilizumab-cdon (Uplizna) will also be indicated for adult patients who are 18 years of age or older with immunoglobulin G4-related disease (IgG4-RD).
Texas Medicaid may approve prior authorization of initial therapy for a 12-month duration for patients who have IgG4-RD if they meet all the following criteria:
- The patient is 18 years of age or older.
- The patient has been diagnosed with IgG4-RD (diagnosis code D8984), and other conditions that mimic IgG4-RD have been ruled out (e.g., malignancy, infection, or other autoimmune disorders).
- The patient is experiencing or has recently experienced an IgG4-RD flare that requires the initiation or continuation of glucocorticoid treatment.
- The patient has a history of IgG4-RD affecting at least two organs.
Providers can refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook, subsection 6.69, “Inebilizumab-cdon (Uplizna),” for additional indications for inebilizumab-cdon (Uplizna).
Renewal or Continuation of Therapy
To renew or continue this drug therapy for patients with neuromyelitis optica spectrum disorder or IgG4-RD, the patient must have previously received inebilizumab-cdon (Uplizna) treatment without complications or unacceptable toxicity (e.g., infusion reactions or serious infections).
Providers can refer to the current TMPPM, Outpatient Drug Services Handbook, subsection 6.69.1, “Prior Authorization Criteria,” for additional requirements for renewal or continuation of therapy.
Next step for providers: Providers should share this communication 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.
