MedicaidPrior AuthMedium impact
Zolgensma® (onasemnogene abeparvovec-xioi) (Revised)
Humana·SC · Pediatrics, Neurology, Genetics·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 25, 2026
Summary
Humana updated its Zolgensma (onasemnogene abeparvovec-xioi) prior authorization policy for Medicaid in South Carolina, effective July 1, 2024, with revision date January 28, 2026. The policy establishes strict eligibility criteria for this gene therapy treatment of spinal muscular atrophy in infants under 2 years of age, including genetic confirmation, anti-AAV9 antibody testing, corticosteroid tolerance, and specialist oversight. Prior authorization is required before any claim submission, with approval limited to a single lifetime dose.
Action Required
Before July 1, 2024 (retroactive update: implement immediately for any pending or future Zolgensma claims): Billing team must implement prior authorization requirement in billing system for all Zolgensma (onasemnogene abeparvovec-xioi) claims for Medicaid members in South Carolina. Configure system to require submission of: (1) genetic confirmation of bi-allelic SMN1 mutations, (2) member age verification (< 2 years), (3) SMN2 gene copy count (≤ 4 copies), (4) anti-AAV9 antibody titer results (≤ 1:50), (5) confirmation of corticosteroid tolerance, (6) evidence of specialist involvement (neurologist), and (7) documentation that member has not previously received Zolgensma. Flag any claims missing these elements for rejection prior to submission. Update provider communication materials and encounter templates to ensure prescribers understand single lifetime dose limitation and all nine required approval criteria. Verify current policy version on Humana website before processing any claims, as policy documents are frequently updated online.