MedicaidPrior AuthMedium impact
Ruconest (C1 esterase inhibitor, recombinant) (Revised)
Humana·KY, SC · Allergy & Immunology, Emergency Medicine, Internal Medicine·Medicaid
We identified it
Jul 23, 2026
Summary
This is a revised Prior Authorization policy for Ruconest (C1 esterase inhibitor, recombinant) affecting Medicaid members in Kentucky and South Carolina. The policy update requires billing teams to verify prior authorization requirements before dispensing or billing for this medication. Specific clinical criteria and authorization procedures may have changed from the previous version.
Action Required
Immediately: Billing and pharmacy teams must obtain the complete revised policy document from the source URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5867de) to review specific prior authorization requirements, clinical criteria, and authorization procedures. Update prior authorization workflows in billing systems for HCPCS code J7205 (Ruconest) for Kentucky and South Carolina Medicaid members. Train staff on any new authorization criteria or documentation requirements. Do NOT bill J7205 without prior authorization confirmation for affected state Medicaid plans. Claims submitted without required prior authorization will be denied.