MedicaidPrior AuthMedium impact
Gazyva® (obinutuzumab)
Humana·OH · Oncology, Hematology, Rheumatology·Medicaid
Effective date
Feb 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Gazyva (obinutuzumab) effective February 1, 2026, covering three indications: chronic lymphocytic leukemia, follicular lymphoma, and lupus nephritis. The policy establishes specific clinical criteria for approval, combination therapy requirements, maintenance duration limits (2-year max for follicular lymphoma), and disease progression exclusions. All requests for this drug now require prior authorization.
Action Required
By January 31, 2026: Billing team must update prior authorization workflows to require PA submission for all Gazyva (obinutuzumab) J9301 claims for Ohio Medicaid members. Implement system rules to flag requests for CLL, follicular lymphoma, and lupus nephritis diagnoses. Providers must verify: (1) for CLL—member is on approved combination therapy (chlorambucil, bendamustine, venetoclax) or monotherapy, and has NOT progressed on Gazyva; (2) for follicular lymphoma—member is first-line OR rituximab-refractory AND initially on chemotherapy combination (reauthorization requires stable/complete/partial response; maintenance capped at 2 years); (3) for lupus nephritis—member is 18+ years old and on standard therapy (corticosteroids with mycophenolate or cyclophosphamide). Update PA submission templates to capture disease status and treatment regimen. Train front desk and billing staff that all Gazyva claims without prior authorization will be denied. Verify member eligibility in Ohio Medicaid plans at time of service.