MedicaidPrior AuthMedium impact
Vyxeos™ (daunorubicin and cytarabine) liposome (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicaid (Ohio) has established a new prior authorization policy for Vyxeos (daunorubicin and cytarabine liposome), effective May 1, 2026. Coverage is limited to newly diagnosed therapy-related AML (t-AML) or AML with myelodysplasia-related changes (AML-MRC), with specific approval durations of up to 2 cycles of induction and 2 cycles of consolidation per 6-month period. Claims for patients with prior disease progression on Vyxeos or conventional daunorubicin/cytarabine regimens will be denied.
Action Required
By April 30, 2026: Billing team must implement prior authorization requirement for all Vyxeos intravenous solution claims for Ohio Medicaid members. (1) Configure billing system to route all Vyxeos claims to Humana's preauthorization system before submission; (2) Create internal checklist requiring clinical staff to verify patient meets Criteria #1 (t-AML or AML-MRC diagnosis) and Criteria #2 (newly diagnosed, post-remission therapy, or re-induction use); (3) Flag claims for automatic denial if patient has any history of disease progression on Vyxeos or conventional 7+3 regimen; (4) Educate oncology providers that initial approval covers maximum 2 induction cycles + 2 consolidation cycles (6 months), with renewal possible at 6-month intervals; (5) Update encounter templates to capture specific disease status and prior therapy history for PA submission. Providers must submit clinical documentation supporting medical necessity before dispensing. Failure to obtain prior authorization will result in claim denials and potential patient balance issues.