MedicaidPrior AuthHigh impact
Abraxane (nab-paclitaxel) (Revised)
Humana·LA · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Nov 1, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Abraxane (nab-paclitaxel) prior authorization policy for Louisiana Medicaid, effective November 1, 2025. This is a pharmacy coverage policy requiring prior authorization for nab-paclitaxel across six cancer indications (breast, melanoma, NSCLC squamous, NSCLC non-squamous, ovarian, and pancreatic). The policy specifies strict clinical criteria for approval, including disease stage/progression status and hypersensitivity documentation requirements. Billing teams must verify all Abraxane claims meet these criteria before submission to avoid denial.
Action Required
Before November 1, 2025: Billing and clinical teams must implement prior authorization processes for all Abraxane (nab-paclitaxel) claims for Louisiana Medicaid members. (1) Update billing software to flag HCPCS code J9264 as requiring prior authorization. (2) Obtain prior authorization before claim submission for all six covered indications: metastatic/recurrent breast cancer with anthracycline history, unresectable/metastatic melanoma as second-line+, NSCLC squamous histology first-line with pembrolizumab/carboplatin, NSCLC non-squamous with no EGFR/ALK mutations using atezolizumab/carboplatin, epithelial ovarian/fallopian tube/primary peritoneal cancer with disease progression or recurrence, and pancreatic cancer (neoadjuvant with gemcitabine or metastatic with gemcitabine). (3) For all indications, verify member has documented hypersensitivity to conventional paclitaxel/docetaxel OR contraindication to standard premedication (except pancreatic cancer, which does not require this). (4) Train providers and clinical staff on documentation requirements. (5) Create prior authorization submission checklist including disease diagnosis, treatment line/status, prior therapy history, and hypersensitivity documentation. Failure to obtain prior authorization will result in claim denials. Reference Humana's PAL portal (www.humana.com/PAL) for current coding requirements.