MedicaidPrior AuthLow impact
Mepsevii™ (vestronidase alfa-vjbk) (New)
Humana·OH · Pediatrics, Internal Medicine, Genetics·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid (Ohio) has established a new prior authorization requirement for Mepsevii (vestronidase alfa-vjbk), a rare enzyme replacement therapy for Mucopolysaccharidosis VII (MPS VII/Sly syndrome). This is a new pharmacy coverage policy effective July 1, 2026, requiring prior authorization for all Mepsevii intravenous infusions in pediatric and adult patients with confirmed MPS VII diagnosis. The policy includes a black box warning for anaphylaxis risk, requiring healthcare professional supervision during infusion.
Action Required
By June 15, 2026: Billing and clinical teams must establish prior authorization workflow for Mepsevii requests through Humana Medicaid Ohio. (1) Update billing software and EMR systems to flag all Mepsevii (vestronidase alfa-vjbk) orders for prior authorization requirement. (2) Providers must document confirmed MPS VII (Sly syndrome) diagnosis on all authorization requests. (3) Clinical staff must verify member eligibility under Medicaid Ohio before processing infusion orders. (4) Reference www.humana.com/PAL for applicable preauthorization and medical coding information. (5) Ensure infusion sites have anaphylaxis response capabilities and protocols in place per black box warning. Failure to obtain prior authorization will result in claim denials.