MedicaidPrior AuthMedium impact
Ekterly® (sebetralstat) (Revised)
Humana·SC · Allergy & Immunology, Pharmacy·Medicaid
Effective date
Aug 27, 2025
We identified it
Jul 21, 2026
Summary
Humana has revised its prior authorization policy for Ekterly® (sebetralstat) for Medicaid in South Carolina, effective August 27, 2025. The policy establishes 8 mandatory criteria for coverage including HAE diagnosis confirmation, specific lab documentation (C4, C1INH levels, and C1q level), specialist treatment requirement, and prior trial/contraindication/intolerance to generic icatibant. For Medicaid requests, step therapy requirements do not apply.
Action Required
By August 27, 2025: Billing and prior authorization team must implement this policy in the authorization system for all Medicaid members in South Carolina seeking Ekterly coverage. Pharmacy staff and providers must ensure: (1) All prior authorization requests include documented HAE Type 1 or 2 diagnosis; (2) Complete lab documentation is attached (C4 level, C1INH antigenic or functional level, C1q level, or known HAE-causing mutation); (3) Verification that member has recurrent angioedema without urticaria and is being treated by allergist/immunologist; (4) Confirmation of no concomitant ACEIs, ARBs, or other angioedema-causing medications; (5) Documentation of previous treatment/response, contraindication, or intolerance to generic icatibant (note: step therapy waived for Medicaid). Update authorization templates and staff training materials to reflect these 8 criteria. Claims submitted without complete documentation of all 8 criteria will be denied. Communicating this to prescribing allergists and immunologists is essential.