Medicare AdvantagePrior AuthHigh impact
Methotrexate Injection (Otrexup®, Reditrex®) (Revised)
Humana·Rheumatology, Dermatology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Medicare Advantage prior authorization policy for Methotrexate Injection (Otrexup and Reditrex) effective January 1, 2023, with the most recent revision dated April 22, 2026. The policy requires prior authorization for coverage of these injectable methotrexate formulations across three indications: severe active rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and severe recalcitrant psoriasis. All requests must demonstrate previous treatment failure or documented intolerance to generic methotrexate before approval.
Action Required
By April 22, 2026 or immediately upon implementation: (1) Billing team must update prior authorization requirements in billing system for all Otrexup and Reditrex claims to mandate documentation of: severe active diagnosis (RA, pJIA, or psoriasis per indication), and previous treatment with or documented intolerance to generic methotrexate. (2) Providers must be notified via updated encounter forms and clinical bulletins to document prior generic methotrexate exposure before submitting Otrexup/Reditrex requests. (3) Prior to claim submission, verify member diagnosis matches one of three covered indications and that required clinical criteria are documented in medical record. (4) Do NOT bill for dosages outside the 7.5-25 mg range in 2.5 mg increments—use alternative methotrexate formulations for other dosing scenarios. (5) Flag any claims lacking documented prior generic methotrexate treatment failure/intolerance for denial prevention. Consequences: Claims submitted without evidence of prior generic methotrexate treatment or meeting clinical criteria will be denied by Humana Medicare Advantage plans.