Medicare AdvantagePrior AuthMedium impact
Defitelio® (defibrotide sodium) (Revised)
Humana·KY, SC, VA · Hematology, Oncology, Transplant Surgery +2 more·Medicaid
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana revised its Defitelio (defibrotide sodium) pharmacy coverage policy effective January 1, 2022, with the most recent revision dated March 25, 2026. This is a prior authorization policy for treating veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) following hematopoietic stem-cell transplantation. The policy requires prior authorization for all uses and explicitly prohibits concomitant use with systemic anticoagulants or fibrinolytic therapy.
Action Required
By April 8, 2026 (within 2 weeks of revision date): Billing and clinical teams must implement the following: (1) Update billing system to flag all Defitelio claims for mandatory prior authorization; (2) Create or revise PA request templates to require documentation of: diagnosis of VOD/SOS following HSCT, presence of renal or pulmonary dysfunction, and confirmation of NO concomitant systemic anticoagulants (enoxaparin, warfarin, apixaban) or fibrinolytic therapy (alteplase); (3) Providers must document minimum 21-day treatment plan at time of PA request; (4) Clinical staff should reject PAs that lack evidence of renal/pulmonary dysfunction or show contraindicated drug combinations. All claims submitted without prior authorization or violating the anticoagulant/fibrinolytic contraindication will be denied. Applicable to Kentucky, South Carolina, and Virginia Medicaid members and Medicare members enrolled with Humana.