MedicaidPrior AuthMedium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·IN · Hematology, Oncology, Critical Care +3 more·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 1, 2026
Summary
This is a revised Humana Medicaid (Indiana) prior authorization policy for Gamifant® (emapalumab-lzsg), an intravenous monoclonal antibody for treating primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. The policy establishes strict criteria requiring documented genetic mutations or clinical HLH-2004 diagnostic criteria, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy for approval. Initial and renewal approvals are limited to 6-month periods.
Action Required
By November 1, 2025: Billing and prior authorization teams must implement this revised Gamifant prior authorization policy in their authorization system for all Indiana Medicaid members. (1) Update PA templates to require documentation of: genetic mutation confirmation (PRF1, UNC13D) OR five of eight HLH-2004 clinical criteria; refractory/recurrent/progressive disease or intolerance to etoposide+dexamethasone; concurrent dexamethasone administration; stem cell transplant candidacy; and treatment phase (induction/maintenance only, must discontinue at conditioning). (2) Configure 6-month approval duration for initial requests and renewals. (3) For renewal requests, require documentation of positive clinical response from baseline while member awaits stem cell transplant. (4) Train providers and billing staff that claims lacking these criteria or submitted without prior authorization will be denied. (5) For HLH/MAS in Still's disease, require separate documentation of: confirmed/suspected Still's disease (sJIA/AOSD), active HLH/MAS diagnosis, and inadequate response/intolerance to glucocorticoids or recurrent MAS. (6) Verify member eligibility is Indiana Medicaid only; this policy does not apply to other state Medicaid programs or non-Medicaid plans.