Medicare AdvantagePrior AuthMedium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
Humana·OH · Neurology, Pharmacy·Medicaid
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) effective August 27, 2025. The policy clarifies coverage criteria for generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP), requiring prior authorization and specific clinical criteria including specialist oversight, documented diagnosis confirmation, and prior treatment history for Medicaid and Medicare Ohio members.
Action Required
By August 27, 2025: Billing and authorization teams must implement prior authorization workflow for Vyvgart and Vyvgart Hytrulo claims for Ohio Medicare and Medicaid members. Update authorization system to enforce the following clinical criteria before claim processing: (1) For gMG: Verify diagnosis, AChR antibody confirmation, neurologist treatment/supervision, and prior treatment with pyridostigmine AND at least one immunosuppressive therapy (note: prior therapy waived for Medicare Part B only). (2) For CIDP (Vyvgart Hytrulo only): Verify diagnosis, neurologist treatment/supervision, and prior treatment or contraindication to IVIG or SCIG. Train billing staff to identify these diagnoses (ICD-10 G70.0x for gMG, G61.81 for CIDP) on claims and submit for prior authorization before billing. Update encounter templates and prior auth forms to capture required clinical documentation. Failure to obtain prior authorization will result in claim denials for non-compliant requests.