MedicaidPrior AuthMedium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 12, 2026
Summary
Humana Medicaid Ohio has revised its prior authorization policy for Epkinly (epcoritamab-bysp), a bispecific antibody for relapsed/refractory B-cell lymphomas. The policy covers DLBCL/high-grade B-cell lymphoma after 2+ prior therapy lines (monotherapy only) and follicular lymphoma under two pathways: monotherapy after 2+ lines OR combination therapy with lenalidomide and rituximab after 1+ lines. Prior authorization is required with initial and renewal approvals valid for 6 months. Critical exclusions include active CNS involvement and prior disease progression on Epkinly or similar CD20-directed agents.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirement in billing system for all Epkinly (epcoritamab-bysp) claims for Medicaid Ohio members. (1) Add Epkinly to PA requirement list in billing software; (2) Configure system to capture diagnosis (DLBCL, high-grade B-cell lymphoma, or follicular lymphoma) and prior therapy line count; (3) Create PA submission checklist confirming: patient has appropriate diagnosis, received required prior systemic therapy lines, and treatment plan complies with policy (monotherapy for DLBCL after 2+ lines; monotherapy OR combination therapy for follicular lymphoma); (4) Flag as exclusionary: active CNS involvement or prior disease progression on Epkinly/CD20-directed CD3 T-cell engager agents; (5) Train providers and billing staff that claims submitted without prior authorization will be denied; (6) Set 6-month renewal reminders for approved cases. Contact Humana's Preauthorization and Notification List (PAL) portal at www.humana.com/PAL for current claim codes and submission procedures.