MedicaidPrior AuthHigh impact
Abecma® (idecabtagene vicleucel) (Revised)
Humana·LA · Oncology, Hematology, Pharmacy·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Abecma® (idecabtagene vicleucel), a CAR-T cell therapy for relapsed or refractory multiple myeloma. The policy requires prior authorization before dispensing, with approval limited to one dose per lifetime over a 60-day duration. Key clinical criteria include diagnosis confirmation, relapsed/refractory disease per IMWG standards, at least two prior lines of therapy (immunomodulatory agent, proteasome inhibitor, anti-CD38 monoclonal antibody), age ≥18 years, and concurrent lymphodepleting chemotherapy. Three exclusions apply: active hepatitis B/C, prior allogeneic transplant, or prior CAR-T therapy.
Action Required
By May 1, 2026: Billing and prior authorization teams must implement the following for all Humana Medicaid (Louisiana) members requesting Abecma: (1) Create or update prior authorization protocols in billing system to require submission of documentation confirming all five clinical criteria (MM diagnosis, relapsed/refractory disease per IMWG, ≥2 prior therapy lines with specified drug classes, age ≥18, planned concurrent lymphodepleting chemotherapy); (2) Configure system to flag and deny any requests that meet exclusion criteria (active HBV/HCV, prior allogeneic transplant, prior CAR-T therapy); (3) Set approval duration limit to 60 days maximum and enforce one-dose-per-lifetime restriction in authorization module; (4) Route all Abecma requests to Humana's Corporate Transplant Department (1-866-421-5663, fax 502-508-9300, email transplant@humana.com) per policy directive; (5) Update provider encounter forms and claim submission instructions to reflect new requirements; (6) Train billing and PA staff on clinical criteria verification process. Failure to obtain prior authorization or submit incomplete clinical documentation will result in claim denials. This policy supersedes any prior Abecma coverage guidance for Louisiana Medicaid.