Medicare AdvantagePrior AuthMedium impact
Hemlibra® (emicizumab-kxwh) (Revised)
Humana·KY · Hematology, Pediatrics, Pharmacy·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
This is a revised Humana prior authorization policy for Hemlibra (emicizumab-kxwh) for hemophilia A treatment, effective for Medicare and Medicaid in Kentucky. The policy establishes four mandatory approval criteria including severe hemophilia A diagnosis, step therapy requirements (with a 365-day continuation exception for Medicare Part B), physician attestation against extended half-life factor VIII use, and confirmation that Hemlibra will be used for prophylaxis. Two exclusions apply: other bleeding disorders and concurrent immune tolerance induction therapy.
Action Required
Before submitting any Hemlibra (emicizumab-kxwh) prior authorization requests for Kentucky Medicare and Medicaid members: (1) Billing/Prior Auth team must verify the member meets ALL four approval criteria—specifically confirm severe hemophilia A status (<1% factor VIII or ≥2 spontaneous bleeding episodes documented), step therapy failure or medical contraindication documented, and physician attestation on file stating no extended half-life factor VIII will be used for breakthrough bleeding. (2) For Medicare Part B continuations within 365 days of prior approval, obtain documentation confirming continuation status to bypass step therapy requirement. (3) Verify member does NOT meet exclusion criteria (no other bleeding disorders or concurrent immune tolerance induction). (4) Update prior authorization submission templates to require physician attestation field and factor VIII inhibitor titer documentation if applicable. (5) Do NOT submit requests for acute bleeding treatment—Hemlibra is prophylaxis only. Claims submitted without complete prior authorization approval will be denied. Route all denials for incomplete criteria documentation back to ordering provider for resubmission.