Medicare AdvantagePrior AuthMedium impact
Enjaymo™ sutimlimab-jome (Revised)
Humana·KY, SC · Hematology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jul 23, 2025
We identified it
Jul 1, 2026
Summary
Humana revised its prior authorization policy for Enjaymo (sutimlimab-jome) for Cold Agglutinin Disease treatment effective July 23, 2025. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires strict prior authorization criteria including diagnosis confirmation, hemoglobin/bilirubin lab values, bacterial vaccination requirements, and restrictions on concomitant rituximab/chemotherapy use. Continuation therapy requires documented efficacy (hemoglobin increase of 2g/dL or more, normalization to ≥12g/dL, or decreased transfusion need).
Action Required
By July 23, 2025: Billing team must implement prior authorization requirements for Enjaymo (sutimlimab-jome) intravenous solution in the billing system. (1) Ensure all initial requests include documentation of: primary CAD diagnosis with chronic hemolysis labs (reticulocyte count, LDH, indirect bilirubin, haptoglobin), positive DAT with C3d, cold agglutinin titer ≥64 at 4°C, hemoglobin ≤10 g/dL, elevated total bilirubin, and proof of encapsulated bacteria vaccination ≥2 weeks prior. (2) Verify member has NOT received rituximab within 3 months or rituximab plus chemotherapy within 6 months, and will not receive concomitant rituximab or chemotherapy. (3) Exclude members with systemic lupus erythematosus diagnosis. (4) For renewal/continuation requests: require evidence of efficacy (hemoglobin increase ≥2g/dL, hemoglobin normalization to ≥12g/dL, or decreased RBC transfusion need) and confirm no concomitant rituximab/chemotherapy. Billing team should add checklist to prior auth request forms and update system rules to block claims without documented prior authorization approval. Provider education recommended on vaccination timing and lab value documentation requirements. Claims submitted without prior authorization will be denied.