Medicare AdvantagePrior AuthLow impact
Cablivi® (caplacizumab-yhdp) (Revised)
Humana·Hematology, Critical Care, Internal Medicine·Medicare Advantage
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana updated its Cablivi (caplacizumab-yhdp) prior authorization policy effective March 25, 2026. The policy reinforces coverage criteria for this rare disease treatment (acquired thrombotic thrombocytopenic purpura) requiring diagnosis confirmation, concurrent or post-plasma exchange therapy, and limits continuation to members with ≤2 recurrences. Initial and renewal approvals are both 3-month intervals.
Action Required
By March 25, 2026: Billing and clinical teams should verify Cablivi prior authorization requests align with updated criteria: (1) confirm aTTP diagnosis with ADAMTS13 levels <10%, (2) verify patient is receiving Cablivi with plasma exchange/immunosuppressive therapy OR within 30 days post-plasma exchange completion, and (3) for renewals, confirm ongoing disease evidence and ≤2 recurrences while on therapy. Update any internal Cablivi authorization templates or protocols to reference the revised 3/25/2026 policy. No workflow changes are required for current processes, but ensure prior auth denials reference correct policy language if members exceed recurrence limits. This is a specialized rare disease therapy affecting very few members; monitor for any Cablivi claims and apply these criteria consistently.