MedicaidPrior AuthMedium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·OH · Hematology, Oncology, Rheumatology +2 more·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 1, 2026
Summary
This is a revised Gamifant (emapalumab-lzsg) prior authorization policy for Ohio Medicaid effective November 1, 2025, with a revision date of June 24, 2026. The policy establishes coverage criteria for two distinct indications: primary HLH requiring documented gene mutation or 5+ clinical characteristics plus failed conventional therapy and stem cell transplant candidacy, and HLH/MAS in Still's disease requiring inadequate response to glucocorticoids or recurrent MAS. All approvals require concurrent dexamethasone administration and carry 6-month initial and renewal periods.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirement for Gamifant (J1602) infusions for Ohio Medicaid members. Update billing system to route all Gamifant claims through prior auth workflow before submission. Providers must document: (1) For primary HLH: gene mutation OR ≥5 HLH-2004 diagnostic criteria; (2) Failure/intolerance of conventional HLH therapy (etoposide + dexamethasone); (3) Stem cell transplant candidacy status; (4) Concurrent dexamethasone administration; (5) For HLH/MAS: confirmed/suspected Still's disease diagnosis, active HLH/MAS, and inadequate response to glucocorticoids or recurrent MAS. Encounter forms and EMR templates must include checklist for required documentation elements. All initial requests require 6-month approval duration; renewals require documentation of positive clinical response if awaiting stem cell transplant. Claims submitted without prior authorization or missing required documentation will be denied for Ohio Medicaid members.