Medicare AdvantagePrior AuthHigh impact
Liposomal doxorubicin (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 Humana prior authorization policy for liposomal doxorubicin (Doxil, Lipodox) effective January 1, 2023, with the most recent revision dated May 27, 2026. The policy establishes specific prior authorization criteria across seven cancer indications (T-cell leukemia/lymphoma, diffuse large B-cell lymphoma, mycosis fungoides/Sezary syndrome, peripheral T-cell lymphoma, breast cancer, Hodgkin lymphoma, Kaposi's sarcoma, multiple myeloma, and ovarian cancer), with distinct approval requirements and combination therapy mandates for each diagnosis. All liposomal doxorubicin claims require prior authorization across Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid.
Action Required
IMMEDIATE ACTION REQUIRED - By end of business today: (1) Billing team must update all billing system rules and prior authorization workflows to require prior auth for ALL liposomal doxorubicin claims (Doxil, Lipodox, generic doxorubicin pegylated liposomal) across Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid plans. (2) Oncology/clinical staff must implement diagnosis-specific approval criteria checklist in EMR or claim submission process, with particular attention to: T-cell lymphoma requiring combination therapy with gemcitabine and vinorelbine; diffuse large B-cell lymphoma requiring documentation of poor ventricular function or frailty; mycosis fungoides/Sezary syndrome; peripheral T-cell lymphoma; relapsed/refractory Hodgkin lymphoma requiring second-line or subsequent therapy; AIDS-related Kaposi's sarcoma with documented treatment failure/intolerance; relapsed/refractory multiple myeloma with Velcade combination requirement; and ovarian cancer with platinum-sensitivity/resistance stratification. (3) Provider education team must distribute this policy to all oncology practices and infusion centers noting the specific combination therapy and line-of-therapy requirements for each indication. (4) Front office and authorization staff must have quick-reference guide for prior auth submission requirements by indication. Failure to obtain prior authorization will result in claim denials. NOTE: Policy revision date of May 27, 2026 indicates very recent updates; verify no additional changes exist in Humana system before finalizing implementation.