MedicaidPrior AuthMedium impact
Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)
Humana·SC, VA · Nephrology, Hematology, Internal Medicine·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Mircera (methoxy polyethylene glycol-epoetin beta) prior authorization policy effective November 26, 2025, for Medicaid members in South Carolina and Virginia. The policy maintains existing coverage criteria for anemia of chronic kidney disease but clarifies prior authorization requirements, iron store documentation thresholds, and hemoglobin monitoring standards for both initial and renewal requests.
Action Required
By November 26, 2025: Billing and clinical teams must update prior authorization workflows for Mircera claims submitted for Medicaid (South Carolina and Virginia) members. Verify that all new and continuation requests include: (1) documented diagnosis of chronic kidney disease/renal failure, (2) hemoglobin <10 g/dL or hematocrit <30 within last 4 weeks for initial requests; hemoglobin <11 g/dL or documented dose adjustment for renewals, (3) iron studies showing transferrin saturation ≥20% OR ferritin ≥100 ng/mL within last 4 months, and (4) documentation that other causes of anemia have been ruled out. Update PA submission templates in billing system to capture these specific criteria. Ensure prior auth approval duration matches plan year for both initial and renewal submissions. Claims submitted without required documentation or meeting these criteria will be denied.