Medicare AdvantagePrior AuthLow impact
Pyrukynd® (mitapivat) (Revised)
Humana·Hematology, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jul 23, 2026
Summary
Humana Medicare Advantage updated its Pyrukynd (mitapivat) prior authorization policy effective January 1, 2023, with a revision dated July 22, 2026. The policy requires prior authorization for Pyrukynd coverage in Medicare Advantage members with pyruvate kinase deficiency and hemolytic anemia, with three specific clinical criteria that must be met before approval. Billing teams must ensure all Pyrukynd claims include documented genetic testing results, hemoglobin levels, and meet exclusion criteria before submission.
Action Required
Before submitting any Pyrukynd claims for Humana Medicare Advantage members: (1) Billing team must verify member meets all three prior authorization criteria: diagnosis of PK deficiency with at least two mutant alleles in PKLR gene (at least one missense), member is not homozygous for R479H or does not have two non-missense variants without another missense variant, and hemoglobin ≤10g/dL; (2) Obtain and attach genetic test results and current hemoglobin lab values to the prior authorization request; (3) Route all Pyrukynd requests through Humana's preauthorization system at www.humana.com/PAL; (4) Ensure providers document that patient has not exceeded 24 weeks without benefit before authorizing continuation. Claims submitted without prior authorization or missing documentation of genetic mutation status and hemoglobin levels will be denied.