Medicare AdvantagePrior AuthMedium impact
Ryplazim (plasminogen, human-tvmh) (Revised)
Humana·FL, KY, SC, VA · Hematology, Pediatrics·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Ryplazim (plasminogen, human-tvmh) effective December 17, 2025, for Medicare and select state Medicaid programs (FL, KY, SC, VA). This is a rare disease therapy requiring prior authorization with four specific clinical criteria: hematologist prescription, confirmed Type 1 plasminogen deficiency diagnosis, baseline plasminogen activity ≤45%, and documented history of associated lesions/symptoms. Billing teams must ensure all four criteria are met before claims are submitted and prior authorization is obtained.
Action Required
Before December 17, 2025: (1) Billing team must implement prior authorization requirement in billing system for Ryplazim (plasminogen, human-tvmh) intravenous solution across all affected Humana plans; (2) Update clinical documentation requirements checklist to capture: hematologist consultation documentation, Type 1 PLGD diagnosis code (ICD-10: E88.02 or similar), baseline plasminogen activity level (≤45%), and documentation of associated lesions (ligneous conjunctivitis, ear/mouth/respiratory/GI/urogenital lesions); (3) Providers must submit prior authorization request with all four criteria documented before dispensing; (4) Front desk staff should flag Ryplazim prescriptions for immediate prior authorization processing; (5) Update EMR templates or encounter forms to prompt for hematology consultation confirmation; (6) Consequence: Claims submitted without prior authorization or missing any of the four criteria will be denied. All affected state Medicaid programs (FL, KY, SC, VA) and Medicare Advantage members require this prior auth; no exceptions.