Medicare AdvantagePrior AuthMedium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·KY, SC · Hematology, Oncology, Rheumatology +2 more·Medicaid
Effective date
Jun 24, 2026
We identified it
Jul 1, 2026
Summary
This is a revised Gamifant® (emapalumab-lzsg) prior authorization policy effective June 24, 2026, covering Medicare and Medicaid (Kentucky and South Carolina). The policy outlines coverage criteria for two indications: Primary HLH with refractory/recurrent/progressive disease or intolerance to conventional therapy, and HLH/MAS in Still's disease with inadequate response to glucocorticoids. Prior authorization is required for all requests, with initial and renewal approvals valid for 6 months.
Action Required
By June 24, 2026: Billing team must implement prior authorization requirements for all Gamifant® (emapalumab-lzsg) claims for Medicare and Medicaid members in Kentucky and South Carolina. Update billing system to flag all Gamifant® claims for PA review before submission. Providers must document one of the following for Primary HLH: (1) confirmed gene mutation (PRF1, UNC13D) OR (2) at least 5 of 8 clinical criteria including fever ≥101.3°F, splenomegaly, cytopenias, elevated ferritin/triglycerides/fibrinogen markers, hemophagocytosis, or low NK cell activity. For HLH/MAS in Still's disease, document diagnosis of sJIA/AOSD AND active HLH/MAS AND inadequate response to glucocorticoids or recurrent MAS. Verify member is a candidate for stem cell transplant and that dexamethasone is administered concomitantly with Gamifant®. Initial approval covers 6 months; renewals require documentation of positive clinical response if awaiting transplant. Claims submitted without prior authorization or missing required clinical documentation will be denied. Contact Humana PAL at www.humana.com/PAL for claim code guidance.