Traditional MedicarePrior AuthMedium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
Humana·KY, SC · Neurology, Pharmacy·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 13, 2026
Summary
Humana revised its prior authorization policy for Vyvgart and Vyvgart Hytrulo (efgartigimod alfa products) effective August 1, 2026, covering treatment of generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP). Key change: Step therapy requirements do NOT apply to Medicaid members, while Medicare members must demonstrate prior treatment failure or contraindication to pyridostigmine and at least one immunosuppressive therapy before approval. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) only.
Action Required
By August 1, 2026: Billing and prior authorization teams must update systems and workflows to distinguish between Medicare and Medicaid processing for Vyvgart/Vyvgart Hytrulo requests. For Medicare requests: Require documentation of prior treatment with pyridostigmine AND at least one immunosuppressive agent (azathioprine, cyclosporine, mycophenolate mofetil, tacrolimus, methotrexate, or cyclophosphamide) before submission. For Medicaid (Kentucky and South Carolina ONLY): Remove step therapy requirements and process approvals based on diagnosis confirmation, specialist supervision, and antibody testing alone. Update PA templates and clinical decision support rules to reflect state-specific requirements. Train providers and staff on the different approval pathways. Ensure claims for out-of-state Medicaid are rejected as this policy does not apply nationally to Medicaid.