Avlayah™ (tividenofusp alfa-eknm) solution (New)

By July 15, 2026: Billing and clinical teams must establish prior authorization workflows for Avlayah intravenous solution (150mg powder for injection) in the Humana Medicaid Ohio system. (1) Update billing software to require prior auth submission before claims processing for this drug. (2) Create internal documentation checklist confirming: patient diagnosis of Hunter Syndrome (MPS II), documentation that treatment is for presymptomatic or symptomatic neurologic manifestations prior to advanced impairment, and patient weight ≥5 kg. (3) Train providers and staff that Avlayah requires prior auth through Humana PAL portal (www.humana.com/PAL) and include medical/procedural coding information. (4) Alert prescribing physicians (typically genetics or metabolic disorder specialists) of new prior auth requirement and three coverage criteria. (5) Implement monitoring protocol: flag claims lacking prior auth approval for immediate denial to prevent payment denials. Failure to obtain prior authorization before dispensing will result in claim denials.