MedicaidPrior AuthMedium impact
Levoleucovorin products (Revised)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid (Louisiana) prior authorization policy for levoleucovorin products (Khapzory, Fusilev, and generics) effective January 1, 2023, with a revision date of September 24, 2025. The policy establishes prior authorization requirements for three indications: osteosarcoma treatment with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer. All three pathways require documented prior leucovorin calcium treatment and evidence of side effects due to lack of efficacy or formulation issues necessitating therapy change.
Action Required
By September 24, 2025: Billing team must implement prior authorization workflow changes for all levoleucovorin product claims submitted to Humana Medicaid (Louisiana). (1) Update billing system to flag levoleucovorin claims for prior authorization before submission. (2) Providers must document: (a) the specific indication (osteosarcoma with high-dose methotrexate, methotrexate toxicity, or advanced metastatic colorectal cancer with 5-FU chemotherapy); (b) prior leucovorin calcium treatment history; (c) documented side effects showing lack of leucovorin calcium efficacy OR formulation-related issues requiring therapy change. (3) Verify members do not have pernicious anemia or megaloblastic anemia secondary to vitamin B12 deficiency (exclusion criterion). (4) For methotrexate toxicity cases, ensure serum methotrexate levels and dosing guidance from the policy are documented and reflected in claims. (5) Direct providers to submit prior authorization requests through Humana's PAL portal at www.humana.com/PAL before dispensing. Claims submitted without prior authorization or missing required documentation will be denied.