Medicare AdvantagePrior AuthMedium impact
Adzynma (ADAMTS13, Recombinant-krhn) (Revised)
Humana·KY, SC · Hematology, Pediatrics, Internal Medicine·Medicaid
Effective date
Apr 24, 2024
We identified it
Jul 22, 2026
Summary
This is a new Humana prior authorization policy for Adzynma (ADAMTS13, recombinant-krhn), a rare enzyme replacement therapy for congenital thrombotic thrombocytopenic purpura (cTTP). The policy establishes four mandatory approval criteria requiring confirmed cTTP diagnosis, ADAMTS13 activity <10 IU/dL, molecular genetic testing confirmation, and repeated negative antibody testing. Billing teams must implement prior authorization requirements for Kentucky and South Carolina Medicaid and all Medicare lines before dispensing.
Action Required
By April 24, 2024 (retroactively effective): Billing and authorization teams must implement prior authorization workflow for Adzynma intravenous kit. Before submitting any claims: (1) Verify member has confirmed cTTP diagnosis with documented ADAMTS13 activity <10 IU/dL at time of diagnosis; (2) Confirm ADAMTS13 mutation identified via molecular genetic testing; (3) Verify repeated negative ADAMTS13 antibody testing has been completed post-therapy; (4) Obtain prior authorization approval from Humana before dispensing medication. Update pharmacy billing system to flag Adzynma claims requiring prior auth for Kentucky Medicaid, South Carolina Medicaid, and Medicare plans. Communicate four approval criteria to prescribing providers and clinical teams. Claims submitted without meeting all four criteria and without prior authorization will be denied. Reference Humana PAL (Preauthorization and Notification List) at www.humana.com/PAL for specific claim codes.