MedicaidPrior AuthHigh impact
Vyloy (zolbetuximab-clzb) (New)
Humana·OH · Oncology, Internal Medicine·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid in Ohio has released a new prior authorization policy for Vyloy (zolbetuximab-clzb), effective October 1, 2025. This intravenous immunotherapy requires prior auth for treatment of HER2-negative, CLDN18.2-positive gastric or gastroesophageal junction adenocarcinoma as first-line combination chemotherapy. Billing teams must implement prior authorization workflows immediately to avoid claim denials.
Action Required
By September 30, 2025: Billing team and clinical staff must implement prior authorization requirement for Vyloy (zolbetuximab-clzb) intravenous infusions in the Medicaid billing system. Update all clinical encounter forms and intake documentation to ensure providers capture: (1) diagnosis of locally advanced unresectable or metastatic HER2-negative gastric/GEJ adenocarcinoma, (2) CLDN18.2-positive status confirmed by FDA-approved test, and (3) intended use as first-line therapy in combination with fluoropyrimidine and platinum-containing chemotherapy. Configure billing system to require prior authorization submission before claim submission. Establish a process for tracking initial 6-month approval periods and renewal submissions. Train front desk and billing staff that claims submitted without prior authorization will be denied. Contact Humana PAL portal (www.humana.com/PAL) for specific medical billing codes if applicable.