Papzimeos™ (zopapogene imadenovec-drba) (New)

REQUIREMENTS: By December 1, 2025: Prior Authorization Team must implement Papzimeos™ prior authorization protocol in billing system for Ohio Medicaid members: 1. Configure system to require prior authorization for all Papzimeos™ subcutaneous suspension claims before submission 2. Billing team must verify ALL four approval criteria are met before requesting authorization: - Biopsy-confirmed diagnosis of Recurrent Respiratory Papillomatosis (obtain pathology report) - Confirmation medication will be administered WITH surgical debulking/removal procedures (coordinate with ENT/surgical providers) - Member is 18 years or older (verify DOB) - Provider submits supporting chart notes documenting policy requirements 3. Check for exclusion: Deny prior auth if member has previous completion of Papzimeos treatment course 4. Ensure prior auth request includes provider documentation of minimal residual disease plan and surgical debulking schedule (pre-treatment, before 3rd dose, before 4th dose) 5. Update encounter forms and provider templates to remind ENT providers that Papzimeos requires prior authorization and must be coordinated with surgical procedures 6. Communicate to billing staff: Claims for Papzimeos without prior authorization will be denied by Humana Ohio Medicaid 7. Refer to www.humana.com/PAL for specific medical billing codes and procedure coding