MedicaidPrior AuthMedium impact
BT202350: IHCP updates PA criteria for HCPCS code J1305 (Evkeeza)
Indiana Medicaid (IHCP)·IN · Cardiology, Endocrinology·Claims & Billing
Effective date
Oct 1, 2021
We identified it
Jun 19, 2026
Summary
Indiana Health Coverage Programs updated prior authorization criteria for HCPCS code J1305 (Evkeeza) injections, effective retroactively from October 1, 2021. New criteria require specific diagnosis, age requirements, specialist prescribing, trial/failure of other medications, and dosage limits for both initial authorization and reauthorization.
Action Required
Immediately: Billing team must update prior authorization requirements for J1305 (Evkeeza) claims in Indiana Medicaid. Verify patients meet all criteria: HoFH diagnosis, age 12+, cardiologist/endocrinologist prescription, trial/failure of Praluent or Repatha (or medical rationale), concurrent lipid-lowering therapy, and dose ≤15 mg/kg every 4 weeks. For reauthorization, ensure LDL-C reduction or goal maintenance is documented. Contact Gainwell Technologies (800-457-4584, option 7) for FFS members or appropriate MCE for managed care members.