MedicaidPrior AuthHigh impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·LA · Oncology, Hematology, Transplant Surgery·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Louisiana Medicaid revised its Kymriah (tisagenlecleucel) prior authorization policy effective May 1, 2026. The policy maintains coverage for three indications (DLBCL, ALL, and Follicular Lymphoma) with updated approval criteria and exclusions. Key requirements include prior authorization through the Corporate Transplant Department, lymphodepleting chemotherapy regimens (unless contraindicated), and a maximum of one dose per lifetime. Multiple exclusions apply, including prior gene therapy, prior anti-CD19 therapy, active hepatitis B/C, HIV/AIDS, and prior allogeneic transplant for lymphoma patients.
Action Required
By May 1, 2026: Billing and clinical teams must implement prior authorization workflow changes for all Kymriah requests through Humana Louisiana Medicaid. (1) Update billing system to require prior auth submission to Corporate Transplant Department (1-866-421-5663; fax 502-508-9300; email transplant@humana.com) before claim submission. (2) Clinical staff must verify ALL approval criteria are met before requesting authorization: patient age requirements (≥18 years for DLBCL/FL; up to 25 years for ALL), prior treatment lines (minimum 2 lines for DLBCL/FL; refractory or 2nd+ relapse for ALL), CD19 expression documentation (for ALL), and planned lymphodepleting chemotherapy use. (3) Billing team must screen for ALL SEVEN exclusion criteria before authorization request, specifically: prior gene therapy, prior anti-CD19/anti-CD3 therapy (blinatumomab, axicabtagene ciloleucel), active hepatitis B/C, HIV/AIDS, active Grade 2-4 GVHD (for pediatric ALL), CNS lymphoma (for B-cell lymphoma), and prior allogeneic transplant (for lymphoma diagnoses). (4) Update encounter templates and prior auth forms to document all required clinical criteria and exclusion screening. (5) Provider education: emphasize that only ONE dose per lifetime is covered and initial/renewal approvals are limited to 60 days duration. (6) Claims without prior authorization or with unmet criteria will be denied. Reference this policy before all Kymriah requests to confirm it remains current with Humana.