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HumanaMedicaid · Prior Auth · Medicaid · SC · Hematology, OncologyHigh impact

Breyanzi® (lisocabtagene maraleucel) (Revised)

Effective date
Jul 1, 2024
Identified
Aug 26, 2026

Summary

Humana updated its Breyanzi® (lisocabtagene maraleucel) pharmacy coverage policy for South Carolina Medicaid, effective July 1, 2024, with most recent revisions dated August 26, 2026. The policy establishes prior authorization requirements for this CAR-T cell therapy across six hematologic malignancies (large B-cell lymphoma at 2L and 3L, CLL/SLL, follicular lymphoma, mantle cell lymphoma, and marginal zone lymphoma) with specific clinical criteria and exclusions that must be verified before claims are processed. Billing teams must implement these requirements to avoid claim denials and ensure members meet eligibility criteria before treatment authorization.

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What to do

Action · 8 steps
01Immediately and before 2024-07-01.
02Billing team must update claims processing system to require prior authorization for Breyanzi component codes J2616, J2617, and J2618 for South Carolina Medicaid members only.
03Create mandatory checklist in billing workflow to verify all five inclusion criteria are met for the member's specific diagnosis (3L LBCL, 2L LBCL, CLL/SLL, follicular lymphoma, mantle cell lymphoma, or marginal zone lymphoma) before submitting authorization request.
04Configure system to confirm member meets diagnosis-specific requirements (e.g., for 3L LBCL: two or more prior lines of therapy + relapsed/refractory disease; for CLL/SLL: prior BTK inhibitor AND BCL-2 inhibitor; for mantle cell: prior BTK inhibitor).
05Add mandatory exclusion screening to deny prior authorization if member has: prior CD-19 CAR-T therapy, active hepatitis B/C, HIV/AIDS, CNS lymphoma, or prior allogeneic transplant.
06Set approval duration limit to 60 days maximum per lifetime with one dose limit in system.
07Update provider education materials and prior authorization request forms to reflect diagnosis-specific criteria.
08Train prior authorization staff on the five distinct clinical pathways and their different requirements.
If missed: Failure to implement prior authorization requirements will result in claim denials for this high-cost therapy ($373K+ per treatment).

Codes mentioned

J2616J2617J2618

Original notice

Breyanzi® (lisocabtagene maraleucel) (Revised)
mcp.humana.com · Always check the source before changing claims.
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Related changes

See all Humana changes →
Breyanzi® (lisocabtagene maraleucel) (Revised)MediumEffective Aug 26, 2026 · Medicare AdvantageBreyanzi® (lisocabtagene maraleucel) (Revised)MediumEffective Aug 26, 2026 · MedicaidBreyanzi® (lisocabtagene maraleucel) (Revised)HighEffective Aug 26, 2026 · MedicaidBreyanzi® (lisocabtagene maraleucel) (Revised)MediumEffective Feb 19, 2026 · Medicare AdvantageBrowse every Humana change in the policy list

Related policy hubs

Humana policiesSC policy changesHematologyOncologyCode J2616Code J2617Code J2618

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