Medicare AdvantagePrior AuthHigh impact
Zilbrysq (zilucoplan) (Revised)
Humana·Neurology, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its prior authorization policy for Zilbrysq (zilucoplan) for Medicare Advantage members with generalized myasthenia gravis (gMG). The policy requires prior authorization and establishes four mandatory approval criteria: confirmed gMG diagnosis, anti-AChR antibody presence, specialist supervision (neurologist), and prior trial or contraindication of Vyvgart products. Critical alert: The drug carries a BLACK BOX WARNING requiring meningococcal vaccination at least 2 weeks before first dose and enrollment in the ZILBRYSQ REMS program.
Action Required
By January 1, 2025 (retroactive to current date - URGENT): (1) Billing team must implement prior authorization process in billing system for all Zilbrysq requests on Medicare Advantage plans; (2) Verify ALL four approval criteria are documented before submitting claims: confirmed gMG diagnosis, anti-AChR antibody test results, neurologist or specialist name/supervision, and evidence of prior Vyvgart (efgartigimod alfa-fcab) or Vyvgart Hytrulo (efgartigimod alfa/hyaluronidase-qvfc) trial or contraindication; (3) Update prior auth templates and encounter forms to capture specialist information and Vyvgart trial history; (4) Alert providers that meningococcal vaccination documentation (serogroups A, C, W, Y, and B) must be on file dated at least 2 weeks prior to first dose, or document medical necessity for expedited dosing; (5) Confirm all prescribers are enrolled in ZILBRYSQ REMS program before processing claims; (6) Denial of claims will occur if prior authorization is not obtained or if required criteria are not documented. Contact Humana at www.humana.com/PAL for specific prior auth submission procedures.