By August 27, 2025: Billing team must implement prior authorization requirements in billing system for Zusduri (mitomycin) claims for Medicare and Medicaid members in Kentucky and South Carolina. Update claim submission processes to verify: (1) member has diagnosis of LG-IR-NMIBC, (2) documented recurrent disease, (3) no prior Zusduri therapy, and (4) no bladder perforation. Configure system to limit approvals to 6 doses per 6-month period. Providers must submit prior authorization requests before dispensing. Train billing staff on new requirement. Update claim denial logic to reject claims missing required documentation or exceeding 6-dose limit. Claims submitted without prior authorization will be denied. Refer to Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for specific medical and procedural coding details.

Effective immediately (August 27, 2025): (1) Billing and pharmacy staff must implement prior authorization requirement for all Zelsuvmi (berdazimer) topical gel prescriptions for Medicare Advantage members. (2) Update billing system/pharmacy software to flag Zelsuvmi claims for mandatory prior auth submission before dispensing. (3) Providers must document on prescription: (a) confirmed molluscum contagiosum diagnosis, and (b) evidence of previous treatment failure, contraindication, or intolerance with at least one conventional therapy (podofilox, cimetidine, or imiquimod). (4) Prior auth requests must include this documentation or claims will be denied. (5) Educate prescribers and front desk staff that Zelsuvmi requires prior authorization—claims submitted without prior auth approval will be denied. (6) Verify current policy status on Humana's online system before processing each claim, as printed copies become uncontrolled.

By August 27, 2025: Billing and prior authorization teams must implement the Thrombate III prior authorization requirement for Indiana Medicaid members. (1) Update billing system to flag all Thrombate III (antithrombin III human) claims for mandatory prior authorization. (2) Create or update prior authorization request templates requiring: confirmed diagnosis of hereditary antithrombin deficiency AND documented clinical use (treatment of thromboembolism, prevention of peri-operative thromboembolism, or prevention of peri-partum thromboembolism). (3) Train authorization reviewers on the two-criterion approval pathway per policy. (4) Communicate requirement to providers administering this drug (typically hematology, anticoagulation clinics, and operating room staff). (5) Verify claim submission processes route to PAL (Preauthorization and Notification List) via www.humana.com/PAL for correct coding. Failure to obtain prior authorization will result in claim denials for Indiana Medicaid members.

By October 1, 2025: Billing team must implement prior authorization requirement for all Zoladex (goserelin) claims for Indiana Medicaid members. Update billing system to route all Zoladex requests to Humana prior auth process. Providers must verify member meets specific criteria before dispensing: (1) Prostate cancer—advanced diagnosis or high recurrence risk; (2) Breast cancer—pre/perimenopausal status AND hormone receptor positive; (3) Endometriosis—3.6 mg dosage only; (4) Endometrial thinning—3.6 mg dosage only for patients scheduled for endometrial ablation. Screen for exclusions: LHRH concomitant use, age under 18, disease progression (breast cancer only), and abnormal vaginal bleeding of unknown etiology. Establish approval durations: prostate/breast cancer = plan year; endometriosis = 6 months; endometrial thinning = 2 months. Update denial templates to cite this policy when criteria are not met. Claims without prior authorization will be denied by Humana.

By October 1, 2025: Billing and prior authorization teams must implement Tivdak prior authorization requirements in the Humana Indiana Medicaid workflow. (1) Establish a prior authorization submission process for Tivdak claims; (2) Create a checklist requiring verification of all four approval criteria (recurrent/metastatic cervical cancer diagnosis, disease progression post-chemotherapy, CPS score ≥1 with documented medical reason against pembrolizumab, and monotherapy use); (3) Train clinical and billing staff on the four mandatory criteria and exclusion rule (disease progression on Tivdak); (4) Update claim submission templates to require prior authorization before pharmacy dispensing; (5) Configure billing system to flag Tivdak claims for prior auth review. Failure to obtain prior authorization will result in claim denials for Indiana Medicaid members. Contact Humana PAL at www.humana.com/PAL for medically billed claim coding requirements.

By January 1, 2026: Billing team must implement prior authorization requirements for all Zurzuvae® claims submitted to Humana Medicare Advantage plans. (1) Update billing system to flag Zurzuvae® prescriptions for mandatory prior authorization before claim submission. (2) Providers must document in patient records: patient age (≥18), DSM-5 major depressive episode diagnosis with validated depression rating scale score (HAM-D, MADRS, or PHQ-9), symptom onset timing (third trimester or within 4 weeks of delivery), postpartum timeline (within 1 year), non-pregnant status at initiation, and confirmation this is the single 14-day course for the current episode. (3) Billing team submits prior authorization requests through Humana with required clinical documentation; initial approval valid 30 days, renewals valid 30 days. (4) Before dispensing, obtain and verify prior authorization approval number. (5) Advise providers of black box warning regarding CNS impairment and driving restrictions—patients must wait ≥12 hours post-administration before driving. Failure to obtain prior authorization will result in claim denials. Contact Humana PAL at www.humana.com/PAL for procedural coding guidance and preauthorization submission.

By January 1, 2026, the billing and prior authorization teams must: (1) Update the prior authorization system to require documentation of intolerance or contraindication to Trazimera (trastuzumab-qyyp) or Kanjinti (trastuzumab-anns) before approving requests for Herceptin, Ogivri, Herzuma, Hercessi, or Ontruzant for Medicaid members in Kentucky and South Carolina (does not apply to Florida Medicaid); (2) Ensure oncology providers document HER2 status (IHC 3+ or IHC 2+/ISH positive) using 2018 ASCO-CAP guidelines in clinical notes before submission; (3) For gastric cancer cases, verify that trastuzumab is prescribed with cisplatin AND either fluorouracil or capecitabine in the treatment plan; (4) Train billing staff to differentiate Florida Medicaid requests (which do NOT require intolerance documentation) from Kentucky and South Carolina Medicaid requests (which DO). Failure to obtain prior authorization or provide required documentation will result in claim denials.

By August 31, 2026: (1) Billing team must update pharmacy billing system to flag Zynlonta (HCPCS J9313) as a PRIOR AUTHORIZATION REQUIRED drug for all Humana Medicaid Indiana members. (2) Configure system to enforce clinical criteria verification before claim submission: member has DLBCL (not otherwise specified OR arising from low-grade lymphoma) OR HGBL; member has relapsed/refractory disease; member has received 2+ lines of prior systemic therapy; and Zynlonta is being used as single agent (no combination therapy). (3) Pharmacy staff and billing team must reject claims if disease progression on Zynlonta is documented (Exclusion #1). (4) Update prior authorization request template to capture required clinical documentation: diagnosis type, prior therapy lines, and disease status. (5) Provider communication: send notice to all oncology providers and dispensing pharmacies that this is a new PA requirement effective immediately; include the clinical criteria checklist. Failure to obtain prior authorization will result in claim denials from Humana Medicaid Indiana.

By September 1, 2026: (1) Billing team must add new HCPCS code J3386 (etuvetidigene autotemcel injection) to billing system and establish it as a new-to-plan coverage code. (2) Update prior authorization workflows to require mandatory medical director review through the Corporate Transplant Department (1-866-421-5663, transplant@humana.com, fax 502-508-9300) before billing any Waskyra claims. (3) Create billing checklist ensuring all four coverage criteria are documented: WAS diagnosis with WAS gene mutation confirmed, patient age ≥6 months, HSCT clinical appropriateness, and absence of suitable HLA-matched related donor. (4) Implement claim edits to deny coverage if patient is pregnant, breastfeeding, or declined contraception (per coverage limitations). (5) Train billing and prior auth staff on the requirement to verify genetic testing documentation and transplant eligibility assessment before submission. (6) Update encounter templates and referral forms to capture pregnancy/reproductive planning status. Failure to route claims through Corporate Transplant Department will result in denials; claims missing required clinical documentation will be rejected.