MedicaidPrior AuthMedium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·OH · Infectious Disease, Gastroenterology, Internal Medicine +1 more·Medicaid
We identified it
Jul 23, 2026
Summary
Humana has issued a new Prior Authorization policy for Vyloy (zolbetuximab-clzb), a monoclonal antibody used for Clostridioides difficile infection prevention. Ohio Medicaid members now require prior authorization before this drug can be administered. The billing team must implement PA requirements immediately to prevent claim denials.
Action Required
Immediately: Billing team must implement prior authorization requirements for Vyloy (HCPCS code J0122) for all Ohio Medicaid claims. Update billing system and EMR to require PA submission before drug administration. Train providers and clinical staff that this is an injectable monoclonal antibody requiring advance approval. Contact Humana at the policy source URL to obtain PA submission guidelines and approval timeframes. Claims submitted without prior authorization will be denied. Note: Policy content is 'Summary Only' — request full policy details from Humana to confirm specific PA criteria, documentation requirements, and any clinical limitations.