Medicare AdvantagePrior AuthMedium impact
Oxlumo® (lumasiran) (Revised)
Humana·Nephrology, Urology, Genetics +2 more·Medicare Advantage
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its prior authorization policy for Oxlumo (lumasiran) on September 24, 2025. The policy maintains strict criteria requiring confirmed PH1 diagnosis via genetic testing or liver biopsy, elevated oxalate levels, specialist prescription, and no prior liver transplant. Initial and renewal approvals are for 6 months or plan year duration. Billing teams must ensure all Oxlumo requests include required clinical documentation before submission to avoid claim denials.
Action Required
By September 24, 2025: Billing team must implement prior authorization verification protocol for all Oxlumo (lumasiran) subcutaneous solution requests for Medicare Advantage members. Before claim submission, verify member meets ALL four initial approval criteria: (1) PH1 diagnosis confirmed by genetic testing (AGXT biallelic pathogenic variants) or liver biopsy showing AGT enzyme deficiency, (2) elevated oxalate levels documented (urine oxalate >0.5 mmol/1.73m²/day, abnormal oxalate:creatinine ratio, or plasma oxalate >2 μmol/L), (3) prescription from nephrologist, urologist, geneticist, or PH-experienced provider, and (4) no prior liver transplant. For renewal requests after 6 months, verify clinical response demonstrated by reduced urinary/plasma oxalate or reduced oxalate:creatinine ratio. Update encounter forms and prior auth checklist to include these specific clinical requirements. Attach all supporting documentation (genetic testing results, lab values, specialist credentials) to PA requests. Store all documentation per retention policy. Communicate requirements to providers through clinical staff. Failure to obtain prior authorization with complete documentation will result in claim denials for this expensive specialty pharmacy agent.