MedicaidPrior AuthMedium impact
Xenpozyme™ (olipudase alfa) intravenous solution (New)
Humana·OH · Pediatrics, Internal Medicine, Genetics·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 13, 2026
Summary
Humana Medicaid Ohio has added a new prior authorization policy for Xenpozyme™ (olipudase alfa), effective August 1, 2026. This intravenous medication treats non-central nervous system manifestations of acid sphingomyelinase deficiency (ASMD) and requires prior authorization with four specific approval criteria, including confirmed ASMD diagnosis, enzymatic/genetic testing, and verification that infusions occur in settings with appropriate medical support (CPR equipment). All claims for this drug must meet these criteria or will be denied.
Action Required
By August 1, 2026: Billing team and provider staff must establish prior authorization processes for Xenpozyme™ (olipudase alfa) intravenous solution. (1) Update billing system to flag all Xenpozyme claims as requiring prior authorization; (2) Create verification checklist requiring confirmation of: ASMD diagnosis, enzymatic assay OR SMPD1 genetic testing documentation, non-CNS manifestations (splenomegaly, hepatomegaly, interstitial lung disease, thrombocytopenia), and administration setting with CPR equipment available; (3) Route all Xenpozyme requests through prior authorization department before claim submission; (4) Update provider documentation templates to capture all four approval criteria; (5) Establish tracking for initial authorization (plan year duration) and renewal requests (plan year duration). Failure to obtain prior authorization will result in claim denials. Reference Humana PAL portal at www.humana.com/PAL for applicable preauthorization codes and procedural coding information.