MedicaidPrior AuthMedium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)
Humana·OH · Oncology, Urology·Medicaid
Effective date
Aug 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicaid Ohio has implemented a revised prior authorization policy for Pluvicto (lutetium Lu 177 vipivotide tetraxetan), a radioligand therapy for metastatic castration-resistant prostate cancer. The policy requires specific criteria including PSMA-positive disease confirmation, prior treatment failure with androgen receptor pathway inhibitors, and limits coverage to a maximum of 6 doses per treatment course.
Action Required
By August 1, 2025: Billing team must implement prior authorization requirements for Pluvicto claims for Ohio Medicaid members. Ensure providers document all four criteria: metastatic castration-resistant prostate cancer diagnosis, PSMA-positive disease confirmation via approved imaging, prior ARPI therapy failure/intolerance with taxane appropriateness, and no prior Pluvicto treatment. Update billing system to track the 6-dose maximum limit. Claims without proper prior authorization will be denied.