Updated Prior Authorization Criteria for Enzyme Replacement Therapy Olipudase Alfa-Rpcp (Xenpozyme) & Esketamine (Spravato)

Date: September 19, 2025

Attention: Providers

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 prior authorization criteria for enzyme replacement therapy olipudase alfa-rpcp (Xenpozyme) and diagnosis code F323 in the list of criteria considered for prior authorization requests for Esketamine (Spravato) (procedure code S0013).

How this impacts providers: For Enzyme Replacement Therapy Olipudase Alfa-Rpcp (Xenpozyme), in addition to diagnosis codes E75241 and E75244, Texas Medicaid will also consider E75240, E75248, and E75249 for prior authorization.

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Outpatient Drug Services Handbook, subsection 6.45, “Enzyme Replacement Therapy (ERT),” for more information about prior authorization criteria. 
For Esketamine (Spravato), also refer to TMPPM, Outpatient Drug Services Handbook, and subsection 6.48.1, Prior Authorization for a list of additional diagnosis codes that Texas Medicaid will consider for prior authorization.

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.