Medicare AdvantagePrior AuthMedium impact
Rituxan Hycela™ (rituximab/hyaluronidase) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jun 24, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Rituxan Hycela (rituximab/hyaluronidase) prior authorization policy effective June 24, 2026, clarifying coverage criteria for chronic lymphocytic leukemia, follicular lymphoma, and diffuse large B cell lymphoma across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). Key changes include maintenance therapy duration limits (2-year maximum for CLL and follicular lymphoma) and exclusion of first-line single-agent use in follicular lymphoma. Billing teams must verify prior authorization requirements before claims submission to avoid denials.
Action Required
By June 24, 2026: Billing and prior authorization teams must update internal workflows and system logic to reflect revised Rituxan Hycela coverage rules. (1) Providers: When submitting Rituxan Hycela requests, document the specific diagnosis (CLL, follicular lymphoma, or DLBCL) and confirm the patient meets all applicable criteria including medical reason for use instead of biosimilars (Ruxience or Riabni) for Medicare Part B continuation claims. (2) Billing/PA Team: Update prior authorization decision trees to flag and deny requests exceeding 2-year maintenance therapy limits for CLL and low-grade NHL (follicular lymphoma). (3) Billing/PA Team: Add system rules to deny first-line single-agent follicular lymphoma requests (Exclusion #2). (4) All staff: Reference the updated policy at www.humana.com/PAL for applicable preauthorization codes and verify patient coverage before processing. Failure to obtain prior authorization or submitting non-compliant requests will result in claim denials.