MedicaidPrior AuthHigh impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·KY · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 26, 2026
Summary
Humana Kentucky Medicaid has revised its Kymriah (tisagenlecleucel) prior authorization policy effective August 26, 2026. The policy maintains three distinct approval pathways for large B-cell lymphoma (DLBCL and follicular lymphoma) in adults ≥18 years, and B-cell precursor acute lymphoblastic leukemia (ALL) in patients up to 25 years. All approvals require prior authorization, are limited to one lifetime dose, and require lymphodepleting chemotherapy unless contraindicated. Key exclusions include prior gene therapy, prior anti-CD19/anti-CD3 therapies, active hepatitis B/C, HIV/AIDS, and (for lymphoma cases) prior allogeneic transplant or CNS lymphoma.
Action Required
By August 26, 2026: Billing team must implement prior authorization requirement for Kymriah (J7174) for all Kentucky Medicaid claims. (1) Update billing system to flag all J7174 claims requiring prior auth before submission. (2) Modify claim submission workflow to route J7174 requests to Corporate Transplant Department (1-866-421-5663, fax 502-508-9300, email transplant@humana.com) for approval before dispensing. (3) Train billing staff to verify member eligibility against all seven criteria for applicable diagnosis (DLBCL/follicular lymphoma or ALL) and ALL six exclusion criteria before submitting requests. (4) Ensure prior auth requests include: diagnosis confirmation, documentation of prior systemic therapy lines (2+ required), evidence of relapsed/refractory disease, CD19 expression results (for ALL), age verification, and lymphodepleting chemotherapy regimen details. (5) Document that maximum one dose per lifetime applies and alert providers/patients of this limitation. (6) Flag claims for members with prior gene therapy, prior anti-CD19/anti-CD3 therapy, hepatitis B (HBsAg-positive), hepatitis C, HIV/AIDS, or (for lymphoma) prior allogeneic transplant or CNS lymphoma for denial. (7) Set initial and renewal approval duration to 60 days in system. Failure to obtain prior authorization will result in claim denials.