MedicaidPrior AuthHigh impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 26, 2026
Summary
Humana Louisiana Medicaid has revised its Breyanzi® (lisocabtagene maraleucel) pharmacy coverage policy effective August 26, 2026. The policy establishes prior authorization requirements for this CAR-T cell therapy across six hematologic malignancies (Large B-cell Lymphoma 3L/2L, CLL/SLL, Follicular Lymphoma, Mantle Cell Lymphoma, and Marginal Zone Lymphoma) with specific clinical criteria, exclusions, and a lifetime maximum of one dose per member. Billing teams must implement prior authorization workflows and verify member eligibility against defined clinical criteria before claims submission.
Action Required
By August 26, 2026: Billing team must update prior authorization system to flag all Breyanzi® (J2335) claims for Louisiana Medicaid members. Create verification checklist requiring documentation of: (1) diagnosis confirmation (Large B-cell Lymphoma, CLL/SLL, Follicular Lymphoma, Mantle Cell Lymphoma, or Marginal Zone Lymphoma); (2) prior therapy lines and specific agents (BTK inhibitor, BCL-2 inhibitor required for CLL/SLL and Mantle Cell; minimum 2 lines for others); (3) relapsed/refractory disease status; (4) member age ≥18; (5) concurrent lymphodepleting chemotherapy plan; (6) confirmation of NO prior CD-19 CAR-T therapy, active hepatitis B/C, HIV/AIDS, primary CNS lymphoma, or prior allogeneic transplant. Providers must submit prior authorization requests before treatment initiation. Update claim denial rules: claims without approved prior authorization or missing clinical documentation will be denied. Communicate policy to oncology providers and clinical staff immediately. Claims submitted after August 26, 2026 without prior authorization approval will be rejected.