Medicare AdvantagePrior AuthHigh impact
Kyprolis® (carfilzomib) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
This is a revised Kyprolis (carfilzomib) prior authorization policy effective January 1, 2022, with the most recent revision dated May 27, 2026. The policy covers multiple myeloma and Waldenstrom's macroglobulinemia treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required for all Kyprolis use, with specific clinical criteria for approval based on disease stage, prior therapy lines, and combination therapy regimens.
Action Required
Immediately: Billing team must verify all Kyprolis (carfilzomib) claims require prior authorization before submission. Update billing software to automatically flag Kyprolis J9047 claims for prior auth review in affected states (FL, KY, SC) and Medicare plans. For each claim, verify: (1) member has confirmed diagnosis of multiple myeloma OR Waldenstrom's macroglobulinemia; (2) regimen meets specific criteria (single agent, combination with dexamethasone, pomalidomide+dexamethasone, lenalidomide+dexamethasone, cyclophosphamide+dexamethasone, or CD38 inhibitor+dexamethasone with appropriate prior therapy lines); (3) member has not experienced disease progression while on Kyprolis (exclusion criteria); (4) corticosteroid omission is documented if intolerance/contraindication exists. Providers must submit prior authorization requests with clinical documentation supporting medical necessity. Claims submitted without prior authorization will be denied. Approval duration is per plan year or as determined through clinical review. Update provider templates and billing workflows to collect required clinical history before claim submission.