Medicare AdvantagePrior AuthHigh impact
Talvey (talquetamab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Talvey (talquetamab) prior authorization policy effective September 24, 2025, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains strict approval criteria requiring multiple myeloma diagnosis, relapsed/refractory disease, at least four prior therapy lines (including specific drug classes), and single-agent use only. A key exclusion applies: members experiencing disease progression on Talvey are not approved. Billing teams must ensure all Talvey claims include prior authorization and verify patient meets all four criteria before claim submission.
Action Required
By September 24, 2025: Billing team must implement the following: (1) Update prior authorization workflows in billing system to require documentation of all four approval criteria (MM diagnosis, relapsed/refractory status, ≥4 prior therapy lines including daratumumab/anti-CD38, proteasome inhibitor, and immunomodulatory agent, and single-agent use); (2) Configure system to block claims if exclusion criteria (disease progression on Talvey) are documented; (3) Create verification checklist for claims processors to confirm prior auth completion before claim submission; (4) Educate oncology providers and nursing staff on the requirement to document prior treatment history and confirm single-agent status; (5) Flag any existing Talvey patients in system for prior auth review if not recently completed; (6) Communicate revised policy to all providers. Failure to obtain prior authorization will result in claim denials. This policy applies to Humana Medicare Advantage, and Medicaid programs in FL, KY, and SC only—verify patient plan type before applying requirements.