MedicaidPrior AuthMedium impact
Vyvgart (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
Humana·SC · Neurology·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicaid in South Carolina has revised its prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), effective July 1, 2024, with most recent updates August 27, 2025. The policy covers two indications: generalized myasthenia gravis (gMG) for both formulations and chronic inflammatory demyelinating polyneuropathy (CIDP) for Vyvgart Hytrulo only. Prior authorization is required for all uses, with specific clinical criteria including confirmed diagnosis, specialist supervision (neurologist), and documented prior treatment/contraindications to first-line therapies.
Action Required
By September 15, 2025: Billing team must verify prior authorization requirements are configured in billing system for all Vyvgart and Vyvgart Hytrulo claims submitted to Humana Medicaid South Carolina. Ensure clinical documentation for all PA requests includes: (1) confirmed diagnosis (gMG with anti-AChR antibodies OR CIDP for Hytrulo only), (2) neurologist treating/supervising, and (3) prior treatment history with pyridostigmine AND at least one immunosuppressive therapy for gMG claims (note: prior therapy requirement does NOT apply to pharmacy benefit requests). Update EMR/encounter forms to include mandatory fields for specialist name and prior treatment documentation. All claims submitted without prior authorization or incomplete clinical criteria will be denied by the payer.