MedicaidPrior AuthMedium impact
Krystexxa® (pegloticase) (New)
Humana·OH · Rheumatology, Internal Medicine, Family Medicine·Medicaid
Effective date
Mar 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicaid Ohio has established new prior authorization requirements for Krystexxa (pegloticase) for refractory chronic gout, effective March 1, 2026. Prior authorization requires meeting 6 specific criteria including chronic gout diagnosis, baseline uric acid >6 mg/dL, methotrexate co-therapy, absence of G6PD deficiency, and failure of conventional therapy including allopurinol.
Action Required
Before March 1, 2026: Billing team must update prior authorization workflows for Krystexxa (pegloticase) for Ohio Medicaid patients. Ensure providers document all 6 criteria: chronic gout diagnosis, baseline serum uric acid >6 mg/dL, methotrexate co-therapy (or contraindication), absence of G6PD deficiency, failure of xanthine oxidase inhibitors, and previous allopurinol treatment/contraindication/intolerance. Update encounter forms and EMR templates to capture required documentation elements for prior authorization requests.