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HumanaMedicaid · Prior Auth · Medicaid · OH · Hematology, Oncology, Internal MedicineHigh impact

Nplate (romiplostim) (New)

Act
by Sep 15, 2026
Effective date
Oct 1, 2026
Identified
Oct 2, 2026

Summary

Humana Medicaid Ohio is implementing a new prior authorization policy for Nplate (romiplostim) effective October 1, 2026, covering three indications: persistent/chronic immune thrombocytopenia (ITP), chemotherapy-induced thrombocytopenia (CIT), and hematopoietic syndrome of acute radiation syndrome (HS-ARS). Billing teams must obtain prior authorization before dispensing, with specific clinical criteria and platelet count thresholds required for each indication.

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What to do

by Sep 15, 2026 · 8 steps
01Billing team and pharmacy staff must implement prior authorization workflow for Nplate (romiplostim) in the Medicaid Ohio billing system.
02Configure system to require prior auth submission for HCPCS J6413 before claim processing.
03Create prior auth templates requiring: (a) For ITP: documented diagnosis of persistent/chronic ITP, current platelet count (<30 x10⁹/L or 30-50 with symptomatic bleeding), and evidence member tried/cannot take corticosteroids or IVIG; (b) For CIT: chemotherapy regimen details, platelet count <100 x10⁹/L, clinical reason (treatment delay/dose reduction/inability to initiate), and exclusion of other causes; (c) For HS-ARS: diagnosis documentation.
04Pharmacy staff must verify renewal criteria before authorizing continuation (ITP: platelet count <400 x10⁹/L; CIT: continued myelosuppressive therapy; HS-ARS: 3-month intervals).
05Update provider communications to highlight exclusions: MDS-related thrombocytopenia (ITP) and lymphoma/AML/high-risk MDS/stem cell transplant (CIT).
06Train front desk and billing staff on new requirements.
07Claims submitted without prior authorization will be denied.
08Contact Humana PAL system (www.humana.com/PAL) for claim code verification.

Codes mentioned

J6413

Original notice

Nplate (romiplostim) (New)
mcp.humana.com · Always check the source before changing claims.
View original ↗

Related changes

See all Humana changes →
Nplate® (romiplostim) (Revised)MediumEffective Jan 1, 2021 · Medicare AdvantageBrowse every Humana change in the policy list

Related policy hubs

Humana policiesOH policy changesHematologyOncologyInternal MedicineCode J6413

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