Medicare AdvantagePrior AuthMedium impact
Vyjuvek™ (beremagene geperpavec-svdt) (Revised)
Humana·KY, SC · Dermatology, Pediatrics·Medicaid
Effective date
Sep 27, 2023
We identified it
Jun 25, 2026
Summary
Humana updated its Vyjuvek (beremagene geperpavec-svdt) prior authorization policy effective September 27, 2023, with a revision date of September 24, 2025. This is a gene therapy for dystrophic epidermolysis bullosa (DEB) requiring prior authorization across Medicare, Kentucky Medicaid, and South Carolina Medicaid. The policy establishes six mandatory approval criteria including patient age (≥6 months), confirmed COL7A1 genetic mutation, dermatologist prescription, no history of squamous cell carcinoma in treatment area, concurrent wound support care, and supporting documentation.
Action Required
By September 27, 2025 (or immediately for new requests): (1) Billing team must configure prior authorization requirement in billing system for Vyjuvek (beremagene geperpavec-svdt) claims submitted to Humana Medicare, Kentucky Medicaid, and South Carolina Medicaid plans. (2) Update claim submission workflow to require ALL six approval criteria be documented before prior auth request is sent: member age verification, genetic testing results confirming COL7A1 mutation, prescribing provider specialty confirmation (dermatologist or DEB-experienced provider), skin cancer history clearance, documentation of concurrent wound care, and supporting chart notes. (3) Providers must include complete documentation package with each authorization request; claims will be DENIED if criteria are incomplete. (4) Front desk and billing staff should flag any Vyjuvek requests from non-dermatology providers for pre-submission verification to avoid denials.