MedicaidPrior AuthMedium impact
Enjaymo™ (sutimlimab-jome) (New)
Humana·IN · Hematology, Internal Medicine·Medicaid
Effective date
Oct 1, 2026
We identified it
Sep 1, 2026
Summary
Humana Medicaid (Indiana) has implemented a new prior authorization policy for Enjaymo™ (sutimlimab-jome), a complement inhibitor for treating hemolysis in adults with primary cold agglutinin disease. Coverage requires strict diagnostic criteria including chronic hemolysis markers, positive DAT testing, cold agglutinin titer ≥1:64, ruled-out secondary causes, hemoglobin ≤10 g/dL, and completion of encapsulated bacteria vaccinations at least 2 weeks prior to therapy initiation.
Action Required
By September 1, 2026: Billing team must establish prior authorization workflow for Enjaymo (sutimlimab-jome) in the billing system for all Indiana Medicaid claims. Create a checklist for providers requiring documentation of: (1) primary CAD diagnosis with chronic hemolysis evidence (reticulocytosis, elevated LDH/bilirubin, low haptoglobin); (2) positive DAT for polyspecific antibodies and C3d; (3) cold agglutinin titer ≥1:64 at 4°C; (4) ruled-out secondary causes (EBV, HIV, lymphoproliferative disease); (5) baseline hemoglobin ≤10 g/dL; and (6) ACIP-recommended encapsulated bacteria vaccinations completed ≥2 weeks before therapy start. Update claim submission forms and provider communication templates. All Enjaymo claims submitted without prior authorization approval will be denied. Direct providers to submit PA requests through www.humana.com/PAL with complete diagnostic documentation.