Medicare AdvantagePrior AuthMedium impact
Poteligeo® (mogamulizumab-kpkc) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Poteligeo (mogamulizumab-kpkc) prior authorization policy effective January 28, 2026, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains prior auth requirements for this oncologic monoclonal antibody used in relapsed/refractory mycosis fungoides or Sézary syndrome, with approval limited to 6-month intervals when used as sole systemic therapy. Key clinical criteria and exclusions remain in place, including denial of coverage for members experiencing disease progression on the drug.
Action Required
By January 28, 2026: Billing team must ensure prior authorization processes are activated for all Poteligeo (mogamulizumab-kpkc) claims across affected plans (Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid). Verify that billing system enforces the three approval criteria: (1) confirmed diagnosis of mycosis fungoides or Sézary syndrome, (2) documented relapsed/refractory disease status, and (3) Poteligeo used as sole systemic therapy. Configure system to flag and deny claims for members with documented disease progression on Poteligeo. Prior auth requests must be resubmitted every 6 months for renewal. Providers should consult the current Poteligeo prescribing information (revised January 2025) for warnings on dermatologic toxicity, infusion reactions, infections, autoimmune complications, and HSCT complications. Claims submitted without prior authorization or failing to meet all three criteria will be denied. Contact Humana's PAL portal at www.humana.com/PAL for current claim codes and preauthorization procedures.