MedicaidPrior AuthMedium impact
Yescarta™ (axicabtagene ciloleucel) (Revised)
Humana·SC · Oncology, Hematology, Transplant Surgery·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicaid (South Carolina) updated its Yescarta (axicabtagene ciloleucel) prior authorization policy effective July 1, 2024, with a revision date of May 1, 2026. The policy covers three indications for this CAR-T cell therapy: Large B-cell lymphoma (3L+), Large B-cell lymphoma (2L with specific refractoriness criteria), and Follicular lymphoma (2L+). All approvals are limited to a maximum of one dose per lifetime with 60-day authorization duration. Billing teams must implement prior authorization requirements and verify member eligibility against specific clinical criteria and five exclusion categories before claim submission.
Action Required
By July 1, 2024: Billing team and prior authorization staff must implement the following: (1) Configure billing system to require prior authorization for Yescarta (HCPCS J9049) for all South Carolina Medicaid claims; (2) Create or update prior auth submission checklist to verify all five clinical criteria are met for the applicable indication (3L LBCL, 2L LBCL, or Follicular Lymphoma); (3) Verify member does NOT meet any of the five exclusion criteria (prior CD-19 therapy, prior CD-19 CAR-T, active Hepatitis B/C, HIV/AIDS, prior allogeneic transplant) before submitting authorization request; (4) Contact Corporate Transplant Department at 1-866-421-5663, fax 502-508-9300, or email transplant@humana.com for all Yescarta authorization requests; (5) Document in claims system that maximum one lifetime dose applies and set 60-day approval window; (6) Update encounter forms and provider communications to indicate lymphodepleting chemotherapy must accompany Yescarta unless contraindicated. Providers must include clinical documentation confirming refractory or relapsed disease per indication-specific definitions. Claims submitted without prior authorization or missing required clinical documentation will be denied.