MedicaidPrior AuthMedium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Louisiana Medicaid has updated its prior authorization policy for Epkinly (epcoritamab-bysp), a bispecific antibody for treating relapsed/refractory B-cell lymphomas. The policy establishes separate approval criteria for DLBCL/high-grade B-cell lymphoma (requiring 2+ prior therapy lines as monotherapy) and follicular lymphoma (allowing either monotherapy with 2+ prior lines OR combination therapy with lenalidomide/rituximab after 1+ prior line). All approvals require prior authorization with initial and renewal periods of 6 months, and CNS involvement or prior disease progression on this drug class are exclusions.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements in the billing system for all Epkinly claims submitted for Louisiana Medicaid members. Before submitting claims, verify: (1) member has DLBCL/high-grade B-cell lymphoma OR follicular lymphoma diagnosis; (2) appropriate prior therapy line requirements are met (2+ lines for DLBCL monotherapy or FL monotherapy; 1+ line for FL combination therapy); (3) no CNS involvement or prior progression on CD20-directed CD3 T-cell engagers; (4) appropriate treatment regimen (monotherapy vs. combination). Obtain prior authorization before dispensing and document approval for 6-month initial period and subsequent 6-month renewals. Without prior authorization, claims will be denied. Update claim submission workflow to include mandatory prior auth step. Notify providers ordering Epkinly of these new requirements and the specific clinical criteria that must be documented in authorization requests.