MedicaidPrior AuthMedium impact
Wainua™ (eplontersen) (Revised)
Humana·OH · Neurology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jun 1, 2026
We identified it
Aug 13, 2026
Summary
Humana Ohio Medicaid has revised its prior authorization policy for Wainua (eplontersen), a pharmacy treatment for hereditary transthyretin-mediated amyloidosis with polyneuropathy. The policy establishes four mandatory approval criteria including TTR gene mutation documentation, polyneuropathy diagnosis with ruled-out alternatives, disability score of IIIb or lower, and no prior liver transplant history. All Wainua claims require prior authorization before dispensing.
Action Required
By June 1, 2026: Billing and prior authorization teams must implement the following for all Wainua (eplontersen) claims submitted to Humana Ohio Medicaid: (1) Establish prior authorization requirement in billing system with mandatory submission before pharmacy dispensing; (2) Create prior auth submission template requiring documentation of: TTR gene mutation confirmation, comprehensive neurologic examination results ruling out other neuropathy causes, polyneuropathy disability score (must be IIIb or lower), and confirmation of no prior liver transplant history; (3) Update provider communication materials and encounter templates to alert prescribers of these four clinical criteria; (4) Train billing staff to verify all four criteria are documented in medical record before submitting PA request; (5) Contact Humana at www.humana.com/PAL to obtain specific medical and procedure coding information for claim submission. Claims submitted without prior authorization or missing required documentation will be denied. Review the full policy at the source URL to confirm this remains current before processing any claims.