MedicaidPrior AuthMedium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 12, 2026
Summary
Humana Indiana Medicaid has issued a revised prior authorization policy for Epkinly (epcoritamab-bysp) effective November 1, 2025, with a revision date of May 1, 2026. The policy covers two indications: (1) DLBCL/high-grade B-cell lymphoma as monotherapy after 2+ prior lines of systemic therapy, excluding patients with CNS involvement or prior progression on Epkinly/CD20-directed CD3 engagers; and (2) Follicular lymphoma as either monotherapy after 2+ prior lines OR in combination with lenalidomide and rituximab after 1+ prior line. All approvals are issued for initial and renewal periods of 6 months or as determined through clinical review, requiring prior authorization before dispensing.
Action Required
Before November 1, 2025: (1) Billing and prior authorization teams must update system workflows to reflect this revised Humana Indiana Medicaid policy. (2) Create or update prior authorization request templates to capture required patient information: diagnosis confirmation (DLBCL NOS, HGBL, or follicular lymphoma), documentation of prior systemic therapy lines, and intended treatment regimen (monotherapy vs. combination therapy with lenalidomide/rituximab). (3) Program system edits to flag and block claims if: patient has active CNS involvement with lymphoma, patient has documented disease progression on Epkinly or CD20-directed CD3 T-cell engagers, or required prior authorization was not obtained. (4) Notify providers and clinical staff of exclusion criteria, particularly CNS involvement screening. (5) Alert pharmacy partners that step-up dosing applies only in Cycle 1 (Days 1, 8, 15, 22) with specific dose escalation per protocol. (6) Ensure all prior auth approvals are issued with 6-month validity; set system reminders for renewal requests at 5.5-month mark. Failure to obtain prior authorization will result in claim denials.