MedicaidPrior AuthMedium impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·KY · Oncology, Hematology, Pharmacy·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Kentucky Medicaid updated its Kymriah (tisagenlecleucel) prior authorization policy effective May 1, 2026, clarifying coverage criteria for three indications: diffuse large B-cell lymphoma (DLBCL), acute lymphoblastic leukemia (ALL), and follicular lymphoma. The policy maintains strict eligibility requirements including prior therapy lines, disease status, age limits, and multiple exclusions (prior gene therapy, prior anti-CD19 therapy, active hepatitis B/C, HIV/AIDS, and for lymphoma patients, prior allogeneic transplant). All approvals are limited to one dose per lifetime with 60-day authorization duration.
Action Required
By May 1, 2026: Billing and clinical teams must implement prior authorization requirements for Kymriah (J7888) claims submitted under Humana Kentucky Medicaid. Update billing system to require documented verification of: (1) diagnosis confirmation (DLBCL, ALL, or follicular lymphoma), (2) prior therapy line documentation (minimum 2 lines for lymphoma; refractory or 2nd+ relapse for ALL), (3) CD19 expression documentation for ALL cases, (4) age verification per indication (≥18 for DLBCL/follicular lymphoma; up to 25 for ALL), (5) lymphodepleting chemotherapy plan documentation, and (6) exclusion screening (no prior gene therapy, no prior anti-CD19/anti-CD3 agents, negative hepatitis B/C/HIV status, no prior allogeneic transplant for lymphoma patients). Providers must submit all prior authorization requests to Humana Corporate Transplant Department (1-866-421-5663; Fax: 502-508-9300; transplant@humana.com). Verify one-dose-per-lifetime limit in patient history before claim submission. Claims without proper prior authorization and documentation will be denied. Front desk and clinical staff should flag ALL Kymriah requests for immediate prior authorization processing given specialized nature and authorization complexity.