Medicare AdvantagePrior AuthMedium impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Feb 19, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Kymriah (tisagenlecleucel) prior authorization policy effective February 19, 2026. The policy maintains coverage for three indications: diffuse large B-cell lymphoma (DLBCL), acute lymphoblastic leukemia (ALL), and follicular lymphoma, with specific clinical criteria and a lifetime maximum of one dose per indication. Billing teams must ensure prior authorization is obtained before claims are submitted, and must verify all clinical criteria are met before proceeding with treatment.
Action Required
By February 19, 2026: (1) Billing team must update prior authorization protocols to reflect the revised Kymriah policy in the billing system. (2) For each patient claim, verify ALL clinical criteria are met before submission: DLBCL patients must have received ≥2 prior lines of therapy, have relapsed/refractory disease, be ≥18 years old, and will use lymphodepleting chemotherapy; ALL patients must be ≤25 years old, have refractory disease or second+ relapse, have documented CD19 expression, and will use lymphodepleting chemotherapy; Follicular lymphoma patients must have ≥2 prior systemic therapy lines, relapsed/refractory disease, be ≥18 years old, and will use lymphodepleting chemotherapy. (3) Ensure exclusion criteria are checked—deny claims for patients with primary central nervous system lymphoma. (4) Coordinate with providers to obtain prior authorization through Corporate Transplant Department (1-866-421-5663, fax 502-508-9300, transplant@humana.com) before infusion. (5) Document that only ONE dose per lifetime will be approved. (6) Providers must confirm lymphodepleting chemotherapy regimen unless contraindicated. Claims submitted without prior authorization or failing to meet clinical criteria will be denied by Humana Medicare Advantage plans.