MedicaidPrior AuthMedium impact
Gattex® (teduglutide) (Revised)
Humana·KY · Gastroenterology, Pharmacy·Medicaid
Effective date
Jan 1, 2019
We identified it
Jun 25, 2026
Summary
Humana updated its Gattex (teduglutide) prior authorization policy for Medicaid beneficiaries in Kentucky, effective January 1, 2019, with a revision date of August 27, 2025. The policy requires prior authorization for Gattex 30-Vial and One-Vial subcutaneous kits for Short Bowel Syndrome patients dependent on parenteral support, with initial approval for 3 months and renewal based on demonstrated decrease in parenteral support volume. Billing teams must ensure claims for this medication include documentation of Short Bowel Syndrome diagnosis, parenteral dependency, absence of active GI malignancy, and absence of biliary/pancreatic disease.
Action Required
By September 30, 2025: Billing team must implement prior authorization workflow for all Gattex (teduglutide) claims for Kentucky Medicaid members. (1) Update billing system to flag Gattex prescriptions for mandatory prior auth requests before claim submission. (2) Ensure prior auth submissions include: member diagnosis of Short Bowel Syndrome, documentation of parenteral nutrition/IV fluid dependency, confirmation of no active GI malignancy, confirmation of no biliary/pancreatic disease. (3) For renewal requests, ensure documentation includes baseline weekly parenteral support volume and current volume to demonstrate decrease. (4) Set approval reminders for 3-month intervals (initial and renewal). (5) Train billing and clinical staff on the four required initial criteria and three renewal criteria. (6) Update claim submission procedures to reference this revised policy dated 8/27/2025. Failure to obtain prior authorization will result in claim denials for Kentucky Medicaid Gattex claims.