Medicare AdvantagePrior AuthMedium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·KY, SC · Hematology, Oncology, Pediatrics +1 more·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Gamifant (emapalumab-lzsg) prior authorization policy effective September 24, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains coverage for primary HLH and HLH/MAS in Still's disease with specific diagnostic criteria, stem cell transplant candidacy requirements, and mandatory dexamethasone co-administration. No coverage expansion or restriction changes are documented in this revision.
Action Required
By September 24, 2025: Billing and authorization teams must verify this is the current policy version at www.humana.com/PAL before processing any Gamifant prior authorization requests. Update internal policy files to reflect the September 24, 2025 revision date. For Kentucky and South Carolina Medicaid and Medicare members requesting Gamifant: (1) Ensure prior authorization is obtained before claim submission; (2) Verify all 5 HLH diagnostic criteria are documented in the medical record; (3) Confirm member is a stem cell transplant candidate; (4) Validate dexamethasone co-administration is prescribed; (5) For continuation requests after 6 months, confirm positive clinical response documentation exists. Claims submitted without proper prior authorization or missing required clinical documentation will be denied. Note: This is a revision to an existing policy (original effective 4/23/2019); verify no superseding policies exist before implementation.