MedicaidPrior AuthMedium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Aug 23, 2023
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Epkinly (epcoritamab-bysp), a bispecific antibody for relapsed/refractory lymphomas. The policy clarifies coverage criteria for DLBCL/high-grade B-cell lymphoma (requires 2+ prior therapy lines as monotherapy, excludes CNS involvement) and follicular lymphoma (allows monotherapy with 2+ prior lines OR combination therapy with lenalidomide/rituximab after 1+ prior line). All approvals are for 6-month periods with clinical review. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility against these specific clinical criteria.
Action Required
Immediately: Billing and pharmacy teams must implement this revised prior authorization policy for Epkinly in billing systems and pharmacy management software across Florida, Kentucky, and South Carolina Medicaid plans. Before processing any Epkinly claims: (1) Verify member meets all applicable criteria (diagnosis type, prior therapy lines, monotherapy vs. combination status); (2) Confirm member does NOT have excluded conditions (CNS involvement or prior progression on Epkinly/CD20-directed CD3 engagers); (3) Obtain prior authorization before dispensing; (4) Set authorization duration to 6 months with clinical review renewal. Update pharmacy encounter forms and clinical review checklists to require documentation of: diagnosis (DLBCL/HGBL or FL), number of prior systemic therapy lines, intended therapy regimen, and CNS status. Route all requests through Humana's PAL system (www.humana.com/PAL) for preauthorization and notification. Claims processed without prior authorization will be denied. Medical directors reviewing requests must document clinical rationale aligning with NCCN Compendium standards.