Medicare AdvantagePrior AuthMedium impact
Nplate® (romiplostim) (Revised)
Humana·Hematology, Oncology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
Humana revised its Nplate (romiplostim) prior authorization policy for Medicare Advantage members, effective January 1, 2021, with the most recent revision dated April 22, 2026. The policy maintains prior authorization requirements for two indications: chronic ITP (requiring platelet count <50 x10⁹/L and documented corticosteroid failure/intolerance) and Hematopoietic Syndrome of Acute Radiation Syndrome (HS-ARS). Initial and renewal approvals are limited to 3-month durations. Billing teams must ensure all requests include required clinical documentation and platelet count verification before submission.
Action Required
Before submitting any Nplate (romiplostim) claims for Medicare Advantage members: (1) Billing team must verify prior authorization is obtained before dispensing—claims will be denied without PA; (2) For initial requests, confirm member meets ALL three criteria for cITP (chronic >6 months ITP, platelet count <50 x10⁹/L, documented corticosteroid failure OR post-splenectomy failure); (3) For HS-ARS requests, confirm diagnosis of radiation exposure-induced thrombocytopenia; (4) Verify member exclusions do NOT apply (no MDS diagnosis, no prior Nplate failure); (5) For continuation therapy, confirm platelet count <400 x10⁹/L; (6) Request 3-month initial approval and 3-month renewal periods; (7) Attach documentation of platelet counts and treatment history with all PA requests. Providers must obtain PA before administration to avoid claim denials and therapy interruption.