MedicaidPrior AuthHigh impact
Abraxane (nab-paclitaxel) (Revised)
Humana·OH · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid (Ohio) prior authorization policy for Abraxane (nab-paclitaxel) effective January 1, 2023 with recent updates as of November 1, 2025. The policy specifies detailed prior authorization criteria across six cancer indications (breast, melanoma, NSCLC squamous, NSCLC non-squamous, ovarian, and pancreatic), with most approvals requiring documented hypersensitivity reactions to conventional paclitaxel/docetaxel or contraindications to standard premedication. Billing teams must verify all prior authorization requirements before dispensing and ensure claims include proper medical necessity documentation.
Action Required
Immediately: Billing and pharmacy teams must implement prior authorization requirements for all Abraxane (nab-paclitaxel) claims under Humana Medicaid (Ohio). Update billing system to require prior auth submission for each of the six covered indications: (1) metastatic/recurrent breast cancer with prior anthracycline therapy or documented hypersensitivity, (2) unresectable/metastatic melanoma as second-line+ with documented hypersensitivity, (3) NSCLC squamous as first-line combination therapy, (4) NSCLC non-squamous with eligible histology, (5) ovarian/fallopian/peritoneal cancer with specific disease status, and (6) pancreatic cancer in combination regimens. Providers must document all required criteria (diagnosis stage, prior therapy status, hypersensitivity reactions or premedication contraindications) on prior authorization requests. Front desk staff must verify prior authorization approval BEFORE dispensing to prevent claim denials. Update encounter forms and clinical templates to capture required documentation elements. Train billing staff to review prescriptions against the six indication-specific criteria matrices. Failure to obtain prior authorization will result in claim denials by Humana. Effective date for this revised policy is November 1, 2025.