MedicaidPrior AuthMedium impact
Factor IX Replacement Products (Hemophilia B) (Revised)
Humana·KY · Hematology, Pharmacy, Pediatrics·Medicaid
Effective date
Jan 20, 2017
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid policy (Kentucky) for Factor IX replacement products used to treat Hemophilia B. The policy was last revised on December 17, 2025 (1 day old) and requires prior authorization for eight Factor IX products. No substantive coverage changes are documented in this revision; the policy maintains existing approval criteria requiring confirmed congenital Hemophilia B diagnosis and use for prophylaxis, on-demand bleeding treatment, or perioperative management.
Action Required
Immediately: Billing team must verify this policy applies to your Kentucky Medicaid contracts. (1) Confirm all Factor IX replacement product claims (AlphaNine SD, Alprolix, BeneFIX, Idelvion, Ixinity, Profilnine, Rebinyn, Rixubis) require prior authorization before submission in your billing system. (2) Update claim submission procedures to require documented evidence of congenital Hemophilia B diagnosis and one of three approved uses: routine prophylaxis, on-demand bleeding treatment, or perioperative management. (3) Train billing and front desk staff that this is a prior authorization requirement—claims submitted without pre-approval will be denied. (4) Reference www.humana.com/PAL for current medically billed claim codes. (5) Alert providers to ensure patient charts document medical necessity aligned with policy criteria before prescribing.