MedicaidPrior AuthLow impact
Qalsody™ (tofersen) (New)
Humana·OH · Neurology·Medicaid
Effective date
Jun 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Qalsody (tofersen), a specialized medication for treating ALS patients with SOD1 gene mutations. The policy requires extensive documentation including genetic testing, baseline lab values, and functional assessments before approval.
Action Required
By June 1, 2026: Billing team must update prior authorization protocols for Qalsody (tofersen) in Medicaid Ohio patients. Ensure providers document: 1) ALS diagnosis by neurologist, 2) SOD1 gene mutation confirmation, 3) elevated plasma neurofilament light chain levels, 4) activities of daily living assessment, 5) ventilation status, and 6) riluzole treatment history. Update encounter forms to include these documentation requirements. Claims will be denied without proper prior authorization and supporting documentation.