All PlansCoverageMedium impact
Therapeutic Radiopharmaceuticals for Prostate Cancer
Blue Cross & Blue Shield of Mississippi·Oncology, Urology, Nuclear Medicine·Medical Policy
We identified it
Jun 20, 2026
Summary
New policy establishes coverage criteria for Lu-177-PSMA-617 (Pluvicto) therapeutic radiopharmaceutical treatment for metastatic castration-resistant prostate cancer. Coverage requires PSMA-positive disease, prior treatment with androgen receptor therapy and taxane-based chemotherapy, with specific dosing and safety guidelines outlined.
Action Required
Immediately: Billing team must establish prior authorization process for Lu-177-PSMA-617 (Pluvicto) claims requiring verification of PSMA-positive mCRPC, prior AR pathway inhibitor treatment, and taxane-based chemotherapy. Update encounter forms to include required documentation checklist for oncology providers. Claims without meeting medical necessity criteria will be denied.