MedicaidPrior AuthMedium impact
Avlayah™ (tividenofusp alfa-eknm) solution (New)
Humana·LA · Pediatrics, Genetics, Neurology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 1, 2026
Summary
Humana Medicaid-Louisiana has established a new prior authorization policy for Avlayah™ (tividenofusp alfa-eknm), an intravenous enzyme replacement therapy for Hunter Syndrome (MPS II) neurologic manifestations. Coverage requires three criteria: confirmed Hunter Syndrome diagnosis, treatment of presymptomatic or symptomatic neurologic manifestations prior to advanced impairment, and patient weight ≥5 kg. This is a brand-new policy effective August 1, 2026, requiring prior authorization for all claims.
Action Required
By August 1, 2026: Billing team must implement prior authorization requirement for all Avlayah (tividenofusp alfa-eknm) intravenous solution claims for Louisiana Medicaid members. Update billing system to flag Avlayah prescriptions and route to prior auth department before claim submission. Clinical staff must verify all three coverage criteria (Hunter Syndrome diagnosis, presymptomatic/symptomatic neurologic manifestation status, and weight ≥5 kg) before obtaining prior authorization. Provide providers with policy summary and prior auth process. All claims submitted without prior authorization will be denied. Reference PAL (Preauthorization and Notification List) at www.humana.com/PAL for specific medical/procedural coding information. Monitor for any alerts regarding infusion-associated reactions, anaphylaxis risk, and required monitoring protocols (hemoglobin levels at baseline, 3 months, and periodically thereafter).