Traditional MedicarePrior AuthHigh impact
Abraxane (nab- paclitaxel) (Revised)
Humana·FL, KY, SC, VA · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Abraxane (nab-paclitaxel) prior authorization policy effective January 1, 2023, with a revision date of September 24, 2025. The policy applies to Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid. Key coverage criteria vary by cancer type (breast, melanoma, NSCLC, ovarian, pancreatic) and require prior authorization with specific clinical requirements such as prior therapy history, hypersensitivity documentation, or specific combination therapy protocols. Note: Florida Medicaid requests are exempt from step therapy requirements.
Action Required
REQUIREMENTS:
- By September 24, 2025 (revision effective date): Billing and clinical teams must review and implement this updated Abraxane prior authorization policy across all affected state Medicaid programs (Florida, Kentucky, South Carolina, Virginia) and Medicare plans.
- Update billing system configuration to require prior authorization for all Abraxane/nab-paclitaxel claims (HCPCS J9264, J9265) for affected payers.
- For each cancer indication (breast, melanoma, NSCLC squamous, NSCLC non-squamous, ovarian, pancreatic), configure system to validate required clinical criteria before claim submission.
- For Florida Medicaid only: Remove step therapy requirement validation from authorization workflow.
- For Medicare Part B continuation requests: Configure system to waive step therapy requirement if prior therapy authorization exists within past 365 days.
- Ensure all prior authorization requests include documented evidence of hypersensitivity reactions to conventional paclitaxel/docetaxel OR contraindication to standard premedications (applicable to most indications).
- Update clinical documentation templates and provider communication materials to highlight specific approval duration: initial coverage for plan year duration or as determined through clinical review; renewals also follow plan year duration.
- Failure to obtain proper prior authorization will result in claim denials. Communicate policy details to all oncology providers and infusion centers.