MedicaidPrior AuthMedium impact
Imaavy intravenous solution (nipocalimab-aahu) (New)
Humana·OH · Neurology, Internal Medicine, Pharmacy·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 4, 2026
Summary
Humana Medicaid (Ohio) has issued a new prior authorization policy effective August 1, 2026 for Imaavy (nipocalimab-aahu), a monoclonal antibody for treating generalized myasthenia gravis (gMG). Billing teams must implement prior authorization requirements for this newly covered medication for anti-AChR or anti-MuSK antibody-positive gMG patients who have failed or cannot tolerate pyridostigmine and at least one immunosuppressive therapy. All claims for Imaavy require prior authorization approval before dispensing to avoid claim denials.
Action Required
By August 1, 2026: Billing and clinical teams must implement prior authorization process for Imaavy (nipocalimab-aahu) in the Humana Medicaid Ohio plan. Specific actions: (1) Update billing system to flag all Imaavy claims as requiring prior authorization; (2) Create prior auth request template requiring documentation of: generalized myasthenia gravis diagnosis, antibody type confirmation (anti-AChR or anti-MuSK), and evidence of prior trial or contraindication to pyridostigmine AND at least one immunosuppressive agent (azathioprine, cyclosporine, mycophenolate mofetil, tacrolimus, methotrexate, or cyclophosphamide); (3) Train pharmacy and clinical staff on approval criteria and documentation requirements; (4) Establish workflow to submit prior authorization requests to Humana before dispensing medication. Consequences: Claims submitted without prior authorization approval will be denied. All Imaavy prescriptions must have documented prior authorization before being filled.