Medicare AdvantagePrior AuthMedium impact
Pyrukynd® (mitapivat) (Revised)
Humana·Hematology, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana has revised its Medicare Advantage prior authorization policy for Pyrukynd® (mitapivat) effective August 27, 2025. The policy establishes specific genetic and clinical criteria for coverage: patients must have pyruvate kinase deficiency with at least two mutant alleles in the PKLR gene (at least one missense), cannot be homozygous for R479H mutation, and must have hemoglobin ≤10 g/dL. Prior authorization is required for all Pyrukynd tablets (5mg, 20mg, 50mg formulations).
Action Required
By August 27, 2025: Billing team must implement prior authorization requirement for all Pyrukynd (mitapivat) prescriptions for Medicare Advantage members. Update billing system and prior auth workflows to require: (1) genetic testing confirmation of PKLR gene mutations with at least one missense mutation, (2) verification that patient does not have homozygous R479H mutation or two non-missense variants only, and (3) current hemoglobin lab value ≤10 g/dL before processing claims. Obtain supporting documentation from prescribing providers including genetic testing results and recent hemoglobin levels. Coordinate with pharmacy team to ensure PA requests include required genetic and laboratory information. Route all Pyrukynd claims through prior authorization process; claims submitted without PA approval will be denied. Provider education recommended on genetic testing requirements and dosing titration schedule (starting 5mg BID, titrating every 4 weeks to maximum 50mg BID).