Medicare AdvantagePrior AuthMedium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·FL, KY, SC · Oncology, Pharmacy·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Elrexfio (elranatamab-bcmm) prior authorization policy effective September 24, 2025. This is a pharmacy coverage policy for relapsed/refractory multiple myeloma requiring prior auth. The policy applies to Medicare and three state Medicaid programs (FL, KY, SC). Key requirements include: patient must have received ≥4 prior lines of therapy including specific drug classes, Elrexfio must be used as monotherapy, and patients with prior BCMA-directed CD3 T-cell engager progression are excluded. Billing teams must implement prior authorization controls for this drug across affected plans.
Action Required
By September 24, 2025: Billing team must implement prior authorization requirements for Elrexfio (elranatamab-bcmm) in billing/claims management systems. Key actions: (1) Update billing software to require prior auth for all Elrexfio claims on Medicare and Medicaid plans in FL, KY, and SC; (2) Create or update prior auth checklist to verify: patient has multiple myeloma diagnosis, relapsed/refractory disease documented, receipt of ≥4 prior therapy lines (including proteasome inhibitor, immunomodulatory agent, anti-CD38 monoclonal antibody), and Elrexfio is single-agent therapy; (3) Flag and deny any claims showing prior BCMA-directed CD3 T-cell engager progression; (4) Inform pharmacy and oncology providers that prior auth must be obtained before dispensing; (5) Train billing staff on new prior auth workflow. Failure to obtain prior authorization will result in claim denials. Note: Policy also applies to Traditional Medicare and Medicare Advantage, so coordinate with both claim submission processes.