Medicare AdvantagePrior AuthMedium impact
Elahere (mirvetuximab soravtansine-gynx) (Revised)
Humana·FL, KY, SC · Oncology, Pharmacy·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Elahere (mirvetuximab soravtansine-gynx) effective March 25, 2026, for treatment of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer. The policy now applies across Medicare, Medicaid (Florida, Kentucky, South Carolina), and requires prior authorization confirmation of five clinical criteria including folate receptor alpha expression testing, prior treatment history, and single-agent use. Billing teams must verify all five approval criteria are met before claim submission or face denial.
Action Required
By March 25, 2026: Billing and clinical teams must implement prior authorization protocol for all Elahere infusions. (1) Update billing system to flag all mirvetuximab soravtansine-gynx claims for mandatory prior auth review before submission. (2) Oncology providers must document in encounter notes that patient meets ALL five criteria: diagnosis confirmation, platinum-resistant disease status, FRa expression ≥75% with 2+ intensity staining, 1-3 prior systemic treatments, and single-agent use. (3) Front desk/authorization team must obtain and attach pathology reports confirming FRa testing results before submitting authorization requests. (4) Verify patient is NOT on Elahere with documented disease progression (exclusion criterion). (5) Establish tracking for required ophthalmic exams (baseline, every other cycle for first 8 cycles, then as clinically indicated) and coordinate with ophthalmology. (6) Update claim submission workflow to include premedication requirements (ophthalmic steroids 6x daily day before through day 4, then 4x daily days 5-8). Failure to obtain prior authorization will result in claim denials. Claims lacking FRa testing documentation or showing disease progression will be rejected.