MedicaidPrior AuthMedium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (New)
Humana·OH · Neurology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicaid Ohio is implementing a new prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), effective September 1, 2026. Coverage requires prior auth approval based on diagnosis confirmation (gMG or CIDP), specific antibody testing or nerve conduction studies, and specialist supervision. This is a completely new policy creating new billing and authorization workflows for these specialty neurology drugs.
Action Required
By September 1, 2026: (1) Billing team must set up prior authorization requirement in billing system for all Vyvgart and Vyvgart Hytrulo claims under Humana Medicaid Ohio plans. (2) Update prior authorization submission procedures to require documentation of: diagnosis of gMG or CIDP; confirmation of anti-AChR, anti-MuSK, anti-LRP4 antibodies OR positive SFEMG/RNS testing (for gMG); specialist name and credentials (neurologist experienced in managing gMG or CIDP). (3) Establish workflows so that neurology practices and pharmacies submit prior auth requests before dispensing/administering these medications. (4) Train front-desk and authorization staff on the two separate approval pathways (gMG vs. CIDP-Hytrulo only). (5) Create encounter templates reminding neurologists to document serology results and specialist status. Claims submitted without prior authorization approval will be denied by Humana Medicaid Ohio.