MedicaidPrior AuthLow impact
Jelmyto (mitomycin) (New)
Humana·LA · Urology, Oncology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicaid Louisiana has established a new prior authorization policy for Jelmyto (mitomycin) pyelocalyceal solution, effective January 1, 2026. This medication treats low-grade upper tract urothelial cancer and requires specific clinical criteria to be met for approval.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements for Jelmyto (mitomycin) pyelocalyceal solution for Louisiana Medicaid patients. Providers must document patient has noninvasive low-grade upper tract urothelial cancer, disease is not metastatic, and patient has no bladder or upper urinary tract perforation. Visit www.humana.com/PAL for specific medical and procedural coding information before submitting claims.