MedicaidPrior AuthMedium impact
Luxturna® (voretigene neparvovec-rzyl) (Revised)
Humana·KY, SC · Ophthalmology, Genetics·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
Humana updated the Luxturna (voretigene neparvovec-rzyl) prior authorization policy on December 17, 2025, for Medicaid coverage in Kentucky and South Carolina. The policy confirms coverage criteria for RPE65 mutation-associated retinal dystrophy with strict eligibility requirements including genetic confirmation, age 12 months to 65 years, and adequate retinal cell viability. Prior authorization is required for all requests with initial 6-month approval duration and 6-month renewal cycles.
Action Required
By December 31, 2025: Billing team must establish prior authorization workflow for Luxturna requests in Kentucky and South Carolina Medicaid plans. For each claim submission, verify: (1) clinical documentation of RPE65 mutation-associated retinal dystrophy diagnosis; (2) positive genetic test confirming biallelic RPE65 mutation (homozygote or compound heterozygote); (3) patient age between 12 months and 65 years; (4) sufficient viable retinal cells per OCT or clinical measures; (5) no prior subretinal gene therapy administration to operative eye. Obtain prior authorization before claim submission and include all supporting documentation. Set reminders for 6-month renewal submissions. Update billing system to flag Luxturna claims for Medicaid KY and SC as requiring pre-authorization. Claims submitted without prior authorization will be denied.