MedicaidPrior AuthMedium impact
Enjaymo™ (sutimlimab-jome) (Revised)
Humana·OH · Hematology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jul 23, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid Ohio has updated its prior authorization policy for Enjaymo (sutimlimab-jome) effective July 23, 2025. This is a revised policy (originally effective July 27, 2022) with updated clinical criteria for initial approval and renewal. The billing team must ensure all Enjaymo claims for Ohio Medicaid members include prior authorization documentation demonstrating patient meets strict diagnostic, lab, vaccination, and medication interaction criteria before dispensing.
Action Required
By July 23, 2025: Billing team must implement prior authorization process for all Enjaymo (sutimlimab-jome) intravenous solution claims for Ohio Medicaid members. Prior to claim submission, verify the following in the patient's medical record: (1) Primary CAD diagnosis confirmed by chronic hemolysis labs (reticulocyte count, LDH, indirect bilirubin, haptoglobin) AND positive DAT for C3d AND cold agglutinin titer ≥64 at 4°C; (2) Hemoglobin ≤10 g/dL; (3) Total bilirubin above normal range; (4) Vaccination against encapsulated bacteria (S. pneumoniae, N. meningitidis serogroups A, C, W, Y, B) completed ≥2 weeks prior to initiation; (5) No rituximab within 3 months prior or rituximab+chemotherapy within 6 months prior, AND no concurrent rituximab or rituximab+chemotherapy planned; (6) No systemic lupus erythematosus diagnosis. For renewal/continuation requests, verify: hemoglobin increase ≥2 g/dL OR hemoglobin normalized to ≥12 g/dL OR decreased transfusion need, AND no concurrent rituximab/chemotherapy. Contact Humana at www.humana.com/PAL for preauthorization submission. Claims submitted without prior authorization documentation will be denied. Providers must be notified of documentation requirements at time of service.