MedicaidPrior AuthMedium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·KY · Oncology, Hematology·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Kentucky Medicaid revised its prior authorization policy for Carvykti (ciltacabtagene autoleucel) effective May 1, 2026. The policy establishes strict approval criteria requiring diagnosis of relapsed/refractory multiple myeloma with prior treatment including immunomodulatory agents, proteasome inhibitors, and anti-CD38 monoclonal antibodies. Coverage is limited to one lifetime dose approved for 60 days, with three key exclusions: active hepatitis B/C, prior allogeneic transplant, and prior CAR-T therapy. All requests must be routed to the Corporate Transplant Department.
Action Required
By May 1, 2026: Billing and authorization teams must implement the revised Carvykti prior authorization workflow. (1) Update billing system to flag all Carvykti requests for mandatory prior authorization through the Corporate Transplant Department (1-866-421-5663, fax 502-508-9300, transplant@humana.com). (2) Develop internal checklist requiring verification of all five approval criteria before submission: MM diagnosis with relapsed/refractory disease (IMWG criteria), ≥1 prior line including immunomodulatory agent + proteasome inhibitor + anti-CD38 monoclonal antibody, patient age ≥18, and use with lymphodepleting chemotherapy (unless contraindicated). (3) Add screening for three exclusion criteria: active hepatitis B/C, prior allogeneic transplant, prior CAR-T therapy. (4) Configure system to enforce one-dose-per-lifetime maximum and 60-day approval duration. (5) Provider education: ensure oncology practices understand IMWG relapsed/refractory definition and required prior therapies. (6) Create denial prevention protocol—claims submitted without prior authorization or missing criterion documentation will be denied. Route all questions and requests to Transplant Department, not standard pharmacy authorization.