MedicaidPrior AuthMedium impact
Vimizim® (elosulfase alfa) (New)
Humana·OH · Pediatrics, Genetics, Internal Medicine·Medicaid
Effective date
Mar 1, 2026
We identified it
Jun 25, 2026
Summary
Humana has established a new prior authorization policy for Vimizim® (elosulfase alfa) effective March 1, 2026, for Ohio Medicaid members. Coverage requires a confirmed diagnosis of mucopolysaccharidosis IVA (MPS IVA; Morquio A Syndrome), with approvals granted for plan year durations on both initial and renewal requests. The policy includes a black box warning for anaphylaxis risk during infusions.
Action Required
By February 15, 2026: Billing team and clinical staff must implement prior authorization workflow for Vimizim (elosulfase alfa) claims for Ohio Medicaid members only. Update billing system to flag all Vimizim requests and route to prior authorization coordinator. Verify member diagnosis of MPS IVA (ICD-10: E76.219 or similar) before claim submission. Communicate to infusion centers and pharmacy providers that prior auth must be obtained before treatment initiation. Set renewal reminders for plan year boundaries to request approval continuations. Claims submitted without prior authorization will be denied. Ensure clinical staff are aware of the black box anaphylaxis warning and document appropriate patient monitoring protocols.