Medicare AdvantagePrior AuthMedium impact
PiaSky® (crovalimab-akkz) injection (Revised)
Humana·FL, KY, SC, VA · Hematology, Internal Medicine, Pharmacy·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 23, 2026
Summary
Humana has updated its prior authorization policy for PiaSky® (crovalimab-akkz) injection, a complement C5 inhibitor for treating Paroxysmal Nocturnal Hemoglobinuria (PNH). The policy, effective January 1, 2025 and revised July 22, 2026, requires prior authorization for all PiaSky requests across Medicare and specific Medicaid programs (Florida, Kentucky, South Carolina, Virginia). Billing teams must verify patients meet all clinical criteria including confirmed PNH diagnosis via flow cytometry, weight ≥40 kg, clinical hemolysis or transfusion dependence, and for Medicare Part B, step therapy with Ultomiris unless continuing prior therapy within 365 days.
Action Required
By January 1, 2025: Billing team must implement prior authorization process for all PiaSky® (crovalimab-akkz) claims. (1) Update billing system to flag all PiaSky requests for prior auth review before claim submission. (2) Create authorization checklist requiring documentation of: confirmed PNH diagnosis by hematologist/PNH specialist, peripheral blood flow cytometry results showing granulocyte PNH clones and Type II/III erythrocyte PNH clones, patient weight ≥40 kg, clinical evidence of hemolysis (LDH >1.5x ULN or ARC >120 cells/μL) OR transfusion dependence, and clinical PNH symptoms. (3) For Medicare Part B requests, obtain step therapy requirement documentation showing patient tried or cannot use Ultomiris, unless request is for continuation within past 365 days. (4) Submit prior auth requests to Humana with complete clinical documentation before dispensing medication. (5) Update provider templates and communication to alert ordering physicians of prior auth requirement. Failure to obtain prior authorization will result in claim denials and delayed medication access.