MedicaidPrior AuthMedium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·LA · Hematology, Oncology, Pediatrics +3 more·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 1, 2026
Summary
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Gamifant® (emapalumab-lzsg) effective November 1, 2025, with revisions dated June 24, 2026. The policy establishes specific criteria for coverage of this IFN-gamma neutralizing antibody for primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. All Gamifant prescriptions require prior authorization with documented evidence of HLH diagnosis, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy.
Action Required
Before November 1, 2025: Billing and clinical teams must implement prior authorization requirement for all Gamifant (emapalumab-lzsg) claims submitted to Humana Louisiana Medicaid. Update billing system to flag all Gamifant prescriptions for mandatory PA review. Providers must submit documentation with each PA request including: (1) confirmation of HLH diagnosis via gene mutation OR ≥5 clinical HLH-2004 criteria; (2) evidence of refractory/recurrent/progressive disease or intolerance to conventional therapy (etoposide + dexamethasone); (3) confirmation of concurrent dexamethasone administration; (4) confirmation of stem cell transplant candidacy; (5) for continuation requests, documentation of positive clinical response from baseline. Initial approvals valid for 6 months; renewal approvals valid for 6 months. For HLH/MAS in Still's disease cases, also require documentation of Still's disease diagnosis (sJIA or AOSD) and inadequate response/intolerance to glucocorticoids or recurrent MAS. Update PA submission templates and provider communication materials. Front desk staff must ensure all Gamifant requests are routed to PA department before claim submission. Failure to obtain prior authorization will result in claim denial.