MedicaidPrior AuthHigh impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·KY · Hematology, Oncology·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
This is a revision to Humana's Kentucky Medicaid prior authorization policy for Breyanzi® (lisocabtagene maraleucel), a CAR-T cell therapy for relapsed/refractory B-cell lymphomas and CLL/SLL. The policy outlines specific clinical criteria, exclusions, and a one-dose-per-lifetime approval limit for multiple indications. The revision date of May 1, 2026 indicates this is an updated version of the original April 21, 2021 policy.
Action Required
By May 1, 2026: Billing team and authorization staff must update prior authorization workflows in the billing system to enforce Breyanzi requirements for Kentucky Medicaid members. Specifically: (1) Implement mandatory prior auth for J9119 (Breyanzi intravenous suspension) and component codes before claims processing; (2) Ensure authorization system captures and validates all 5 criteria for each indication (Large B-cell Lymphoma 3L, Mantle Cell Lymphoma, Large B-cell Lymphoma 2L, CLL/SLL, Follicular Lymphoma); (3) Program system to automatically deny or flag for manual review any claims from members meeting ANY exclusion criteria (prior CD-19 CAR-T therapy, active hepatitis B/C, HIV/AIDS, CNS lymphoma, prior allogeneic transplant); (4) Configure system to enforce maximum one-dose-per-lifetime rule by blocking subsequent authorization requests after initial 60-day approval; (5) Update authorization templates to capture treatment history requirements (e.g., BTK inhibitor for MCL and CLL/SLL, chemoimmunotherapy response for 2L LBCL); (6) Train authorization staff on condition-specific criteria variations. Failure to implement these controls will result in claim denials, member appeals, and compliance violations.