MedicaidPrior AuthMedium impact
Leqvio® (inclisiran) (Revised)
Humana·OH · Cardiology, Internal Medicine, Family Medicine +1 more·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Humana Medicaid (Ohio) has revised its prior authorization policy for Leqvio® (inclisiran) effective July 1, 2026. The policy clarifies coverage criteria for hypercholesterolemia and heterozygous familial hypercholesterolemia (HeFH) patients aged 18+, requiring adjunctive therapy to maximally tolerated statins or documentation of statin-associated muscle symptoms (SAMs). A separate pathway covers pediatric homozygous familial hypercholesterolemia (HoFH) patients aged 12+. All Leqvio prescriptions now require prior authorization before dispensing.
Action Required
By July 1, 2026: Billing and clinical staff must implement prior authorization requirements for all Leqvio (inclisiran) subcutaneous syringe prescriptions submitted to Humana Medicaid Ohio. Before submission, verify: (1) member diagnosis (hypercholesterolemia, HeFH, or HoFH); (2) age requirements (18+ for general hypercholesterolemia, 12+ for HeFH/HoFH); (3) statin failure documentation or SAMs attestation from provider. Update prior auth workflow in billing system to flag Leqvio claims for manual review. Ensure providers document maximally tolerated statin use, LDL-C levels, and reason for Leqvio initiation (failed LDL reduction OR SAMs with provider attestation). Include SAMs documentation (rhabdomyolysis, failed statin re-challenge, or intolerance attestation) in PA requests. Route all claims through prior authorization process at www.humana.com/PAL. Claims submitted without prior authorization will be denied.