MedicaidPrior AuthMedium impact
Enjaymo™ (sutimlimab-jome) (Revised)
Humana·OH · Hematology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jul 27, 2022
We identified it
Jul 1, 2026
Summary
This is a revised Medicaid (Ohio) prior authorization policy for Enjaymo (sutimlimab-jome), a complement inhibitor for cold agglutinin disease. The policy establishes strict initial authorization criteria including diagnosis confirmation, hemoglobin thresholds, vaccination requirements, and rituximab interaction restrictions, plus renewal criteria based on demonstrated efficacy. Billing teams must implement prior authorization requirements before claims submission.
Action Required
Before processing any Enjaymo claims for Ohio Medicaid members: (1) Billing and prior authorization teams must verify this is a prior authorization drug requiring approval before dispensing; (2) Implement workflow to collect and validate all six initial authorization criteria from providers before submitting PA requests (diagnosis confirmation with labs, hemoglobin ≤10 g/dL, elevated total bilirubin, vaccination documentation, no recent rituximab, no SLE diagnosis); (3) For continuation/renewal requests, ensure efficacy documentation is submitted showing either 2+ g/dL hemoglobin increase, hemoglobin normalization to ≥12 g/dL, or reduced transfusion need; (4) Train billing staff to flag and deny claims lacking prior authorization; (5) Update internal PA tracking system to note the June 24, 2026 revision date and verify current policy version before each submission at www.humana.com/PAL. Failure to obtain prior authorization will result in claim denial.