Medicare AdvantagePrior AuthMedium impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Feb 19, 2026
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Breyanzi (lisocabtagene maraleucel), a CAR-T cell therapy for relapsed/refractory B-cell lymphomas and leukemias. The policy was updated on February 19, 2026, and maintains strict approval criteria including documented prior therapy lines, disease refractoriness/relapse timing, age ≥18, concurrent lymphodepleting chemotherapy, and a lifetime maximum of one dose per member. Primary CNS lymphoma cases are excluded.
Action Required
By February 19, 2026: Billing and prior authorization teams must ensure Humana Medicare Advantage plan systems are updated to reflect this revised policy. (1) Verify that all prior authorization requests for Breyanzi (J9154) require documented evidence of: at least 2 prior therapy lines (or specific BTK/BCL-2 inhibitors for CLL/SLL), relapsed or refractory disease status with specific timing criteria, member age ≥18 years, and planned concurrent use of lymphodepleting chemotherapy. (2) Update authorization submission templates and clinical review criteria to match the indication-specific requirements for Large B-cell Lymphoma (3L and 2L), CLL/SLL, Follicular Lymphoma, Mantle Cell Lymphoma, and Marginal Zone Lymphoma. (3) Configure systems to deny or refer for clinical review any requests for Primary CNS Lymphoma cases. (4) Ensure all approvals are limited to 60-day duration with a lifetime maximum of one dose tracked at the member level. (5) Provide updated clinical review guidelines to clinical staff and medical directors. (6) Update provider communication materials and billing guides. Failure to implement these requirements will result in claim denials for non-compliant prior authorization submissions.