Medicare AdvantagePrior AuthHigh impact
IVIG (immune globulin) (Revised)
Humana·KY, SC · Hematology, Infectious Disease, Neurology +4 more·Medicaid
Effective date
Jan 1, 2026
We identified it
Jul 21, 2026
Summary
Humana revised its IVIG (immune globulin) pharmacy coverage policy effective January 1, 2026, with updates as of July 22, 2026. The policy clarifies prior authorization requirements, preferred product selections, and clinical criteria for coverage across 24 IVIG formulations for Medicare and Medicaid (Kentucky and South Carolina) members. Key requirements include step therapy with preferred products unless prior therapy/intolerance documented, specific clinical thresholds (e.g., IgG levels, platelet counts), and condition-specific approval criteria for 22 listed indications.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements in billing software for all IVIG claims (J-codes listed above) for Kentucky and South Carolina Medicaid and Medicare members. Update claims submission protocols to enforce step therapy: require documentation of prior therapy or documented intolerance when non-preferred products (Hizentra, Gammaked, Gamunex-C, Hyqvia, Cuvitru, Panzyga, Cutaquig, Xembify, Asceniv, Bivigam, Alyglo, Gammaplex, Yimmugo, Qivigy, GamaSTAN) are requested. For continuation therapy within 365 days on Medicare Part B, bypass step therapy requirement. Preferred products are: Flebogamma DIF, Gammagard, Gammagard S/D, Gammaked, Gamunex-C (Medicare Part D primary), Hizentra, Octagam, Privigen, and Xembify. Prior to submission, clinical staff must verify member meets indication-specific criteria (documented diagnosis, required lab values per indication: IgG thresholds ranging 400-600 mg/dL, platelet counts, etc.). BvsD (Brand vs. Generic) coverage determination may be required—verify in system before authorization. Failure to obtain prior authorization will result in claim denials. Notify providers of updated requirements and preferred product list.