Medicare AdvantagePrior AuthMedium impact
Hemgenix (etranacogene dezaparvovec-drlb) (Revised)
Humana·KY, SC · Hematology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jun 1, 2023
We identified it
Jun 25, 2026
Summary
Humana updated its Hemgenix (etranacogene dezaparvovec-drlb) prior authorization policy effective June 1, 2023, with a revision date of April 22, 2026. This gene therapy for Hemophilia B now requires prior authorization with five specific approval criteria: patient age ≥18 years, diagnosed Hemophilia B with prior Factor IX prophylaxis or serious bleeding history, no Factor IX inhibitors present, no significant liver dysfunction, and no previous gene therapy. The policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina with 60-day initial and renewal approval durations.
Action Required
By April 22, 2026 (revision date): Billing and prior authorization teams must implement Hemgenix prior authorization requirements in their systems for Medicare, Medicaid-Kentucky, and Medicaid-South Carolina members. Before submitting claims, verify all five approval criteria are met: (1) member age ≥18, (2) Hemophilia B diagnosis with documented Factor IX prophylaxis history (≥12 months) OR life-threatening hemorrhage history OR repeated serious spontaneous bleeding, (3) documented absence of Factor IX inhibitors from provider, (4) no significant liver dysfunction confirmed by normal LFTs and hepatic imaging with hepatologist attestation if needed, and (5) no prior gene therapy. Update prior authorization workflows to require provider documentation of these specific criteria. Set approval duration to 60 days for both initial and renewal requests. Failure to obtain prior authorization before administration will result in claim denials. Update encounter templates and preauthorization checklists to capture required clinical documentation.