Medicare AdvantageCoverageMedium impact
MA08.104c, Emapalumab-lzsg (Gamifant®)
Independence Blue Cross·Hematology, Oncology, Pediatrics·Pharmacy
Effective date
Jul 28, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage policy MA08.104c for Emapalumab-lzsg (Gamifant®) has updated medical necessity criteria and medical coding requirements. This affects billing and coverage determination for this specialty pharmaceutical product used to treat hemophagocytic lymphohistiocytosis.
Action Required
By July 28, 2025: Billing team must review updated medical necessity criteria for Emapalumab-lzsg (Gamifant®) in Medicare Advantage plans. Update prior authorization documentation requirements and verify coding guidelines for this specialty drug. Providers must ensure medical necessity documentation meets new criteria to avoid claim denials.