Medicare AdvantagePrior AuthMedium impact
Wainua™ (eplontersen) (Revised)
Humana·KY, SC, VA · Neurology, Internal Medicine, Pharmacy·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana has revised its Wainua (eplontersen) pharmacy coverage policy effective March 25, 2026, for treatment of polyneuropathy of hereditary transthyretin-mediated amyloidosis. This is a prior authorization policy affecting Medicare and Medicaid members in Kentucky, South Carolina, and Virginia. Coverage requires documentation of TTR gene mutation, active polyneuropathy with ruled-out alternative causes, polyneuropathy disability score of IIIb or lower, and no prior liver transplant history.
Action Required
Before March 25, 2026: Billing and prior authorization teams must implement this policy change for Wainua (eplontersen) pharmacy claims. SPECIFIC ACTIONS: (1) Update prior authorization workflow in billing system to require PA for both Wainua subcutaneous auto-injector and prefilled syringe formulations; (2) Create/update PA request template to require documentation of: TTR gene mutation confirmation, comprehensive neurologic examination results ruling out other neuropathy causes, current polyneuropathy disability score (IIIb or lower), and confirmation of no prior liver transplant; (3) Train billing team and prior authorization staff on the four clinical approval criteria; (4) Update provider communication materials for Kentucky, South Carolina, and Virginia practices; (5) Verify claim submission routing for all three affected Medicaid state plans. CONSEQUENCES: Claims submitted without proper prior authorization or missing required clinical documentation will be denied. This applies only to the three specified Medicaid plans and Medicare beneficiaries in the affected states.