MedicaidPrior AuthMedium impact
Stem cell mobilizing agents (Mozobil, Aphexda, Plerixafor) (New)
Humana·OH · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Ohio implemented a new prior authorization policy (effective July 1, 2026) for stem cell mobilizing agents (Mozobil, plerixafor, Aphexda). Coverage requires diagnosis of NHL or MM, concurrent use with G-CSF/GM-CSF, and use within autologous stem cell transplant protocols. Usage is strictly limited: Mozobil/plerixafor to 4 consecutive days maximum; Aphexda to 2 doses maximum. Billing team must obtain prior auth before dispensing and verify compliance with all three approval criteria and exclusion limits.
Action Required
By July 1, 2026: Billing team must implement prior authorization requirement in pharmacy billing system for all claims involving Mozobil (plerixafor), plerixafor, and Aphexda (motixafortide) for Humana Medicaid Ohio members. Before submitting claims, verify: (1) member has diagnosis of NHL or MM (Aphexda requires MM only); (2) concurrent prescription exists for G-CSF or GM-CSF; (3) therapy is part of documented autologous stem cell transplant mobilization protocol; (4) usage does not exceed 4 consecutive days for Mozobil/plerixafor or 2 doses for Aphexda; (5) usage ends upon stem cell harvest/apheresis completion. Update claim submission workflow to flag any requests exceeding these limits. Communicate these requirements to all dispensing providers and pharmacy staff. Claims submitted without prior authorization or exceeding usage limits will be denied. Coordinate with oncology and hematology practices that may initiate these therapies.