Medicare AdvantagePrior AuthMedium impact
Gazyva® (obinutuzumab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Rheumatology·Medicaid
Effective date
Jan 1, 2020
We identified it
Aug 12, 2026
Summary
Humana has revised its Gazyva (obinutuzumab) prior authorization policy effective January 1, 2020, with the most recent update dated December 17, 2025. This pharmacy coverage policy applies to Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina) and establishes prior authorization requirements for Gazyva use in chronic lymphocytic leukemia, follicular lymphoma, and lupus nephritis. Key criteria include specific combination therapy requirements, disease progression exclusions, and maintenance therapy duration limits that must be verified before claim processing.
Action Required
Immediately: Billing team must update prior authorization workflows to require manual review for all Gazyva (J9301) claims across Medicare Advantage, Traditional Medicare, and Medicaid (FL, KY, SC) members. Verify claims meet specific criteria: (1) For CLL: combination therapy with chlorambucil, bendamustine, venetoclax, or monotherapy; (2) For follicular lymphoma: first-line therapy OR relapsed/refractory post-rituximab with chemotherapy combination, with renewal requiring stable/complete/partial response and maintenance not exceeding 2 years; (3) For lupus nephritis: age 18+, with standard therapy combination. Deny claims for any patient with documented disease progression on Gazyva. Update encounter forms and billing system rules to flag these criteria. Train billing staff to submit prior authorization requests to Humana's PAL system (www.humana.com/PAL) before adjudication. Without prior authorization, claims will be denied by Humana across all affected plans and states.