Medicare AdvantagePrior AuthMedium impact
Uplizna® (inebilizumab-cdon) (Revised)
Humana·KY, SC · Neurology, Rheumatology, Allergy & Immunology·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Uplizna (inebilizumab-cdon) prior authorization policy effective March 25, 2026, affecting Medicare and Medicaid (Kentucky and South Carolina) coverage for four indications: NMOSD, IgG4-RD, anti-AChR gMG, and anti-MuSK gMG. The policy maintains prior authorization requirements with specific clinical criteria and step therapy requirements that vary by indication and plan type (Medicare Part B, Part D, or Medicaid). Billing teams must verify which line of business applies and ensure claims include required prior authorization before submission.
Action Required
By March 25, 2026: (1) Billing team must update prior authorization workflow to reflect revised Uplizna policy for three lines of business: Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. (2) Create or update authorization checklists in billing system to enforce the following: For NMOSD requests—verify AQP4 antibody positive status AND one core clinical characteristic AND (for Medicare Part B only) prior trial/contraindication to Ultomiris. For IgG4-RD—verify clinical diagnosis AND prior trial/failure/contraindication to glucocorticoids. For anti-AChR gMG—verify diagnosis, antibody confirmation, neurologist supervision, AND step therapy per plan type (Part D: Vyvgart/Vyvgart Hytrulo; Part B: Vyvgart/Vyvgart Hytrulo AND Ultomiris; Medicaid: pyridostigmine AND one immunosuppressive). For anti-MuSK gMG—verify diagnosis, antibody confirmation, specialist supervision, AND pyridostigmine plus immunosuppressive (except Medicare Part B). (3) Front desk and providers must not submit claims without completed prior authorization; failure to obtain pre-approval will result in claim denial. (4) Update encounter templates and authorization request forms to include diagnosis verification, antibody status documentation, specialist confirmation, and medication trial history as applicable.