Medicare AdvantagePrior AuthMedium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Feb 25, 2026
We identified it
Aug 12, 2026
Summary
Humana revised its prior authorization policy for Epkinly (epcoritamab-bysp) effective February 25, 2026, covering treatment of relapsed/refractory DLBCL, high-grade B-cell lymphoma, and follicular lymphoma across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains prior authorization requirements with specific clinical criteria for approval, including prior therapy thresholds and monotherapy/combination therapy options.
Action Required
By February 25, 2026: Billing and prior authorization teams must implement the revised Epkinly policy in their authorization systems. For DLBCL/high-grade B-cell lymphoma cases, ensure prior auth requests include documentation of: (1) confirmed diagnosis of DLBCL NOS or HGBL, (2) proof of two or more prior systemic therapy lines, (3) confirmation of monotherapy use, and (4) absence of CNS involvement or prior Epkinly/CD20-directed CD3 T-cell engager progression. For follicular lymphoma cases, verify either: monotherapy with 2+ prior lines OR combination with lenalidomide/rituximab with 1+ prior lines. Set approval duration to 6 months initial and 6 months for renewals. Update prior authorization request forms and provider communication templates to reflect these specific criteria. Train authorization staff on the two distinct approval pathways (DLBCL vs. FL) to prevent claim denials. Coordinate with oncology providers to ensure documentation supports the clinical criteria before submission.