Medicare AdvantagePrior AuthMedium impact
Isatuximab-irfc Products (Sarclisa, Sarclisa Escena) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
May 27, 2026
We identified it
Jul 22, 2026
Summary
Humana revised its prior authorization policy for Isatuximab-irfc (Sarclisa, Sarclisa Escena) effective May 27, 2026, covering three multiple myeloma indications across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy maintains prior authorization requirements with specific combination therapy criteria and excludes patients with prior anti-CD38 inhibitor disease progression. Approval duration remains 6 months for initial and renewal periods.
Action Required
By May 27, 2026: Billing and prior authorization teams must update systems to implement the revised Isatuximab-irfc (Sarclisa, Sarclisa Escena) policy for Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina plans. Update prior authorization workflows to enforce the three indication-specific criteria sets: (1) Third-line MM requiring pomalidomide + dexamethasone combination with ≥2 prior therapies including lenalidomide and proteasome inhibitor; (2) Relapsed/refractory MM requiring carfilzomib + dexamethasone combination with ≥1 prior therapy; (3) Newly diagnosed MM requiring bortezomib + lenalidomide + dexamethasone for transplant-ineligible patients. Configure system to automatically deny requests for patients with prior anti-CD38 inhibitor disease progression. Train prior authorization and billing staff on the updated criteria. Add 6-month renewal tracking for all approvals. Failure to implement updated criteria will result in claim denials and prior authorization delays.