Medicare AdvantagePrior AuthHigh impact
Rituximab Products (Revised)
Humana·Hematology, Oncology, Rheumatology +1 more·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Rituximab Products prior authorization policy effective January 1, 2023, with a revision date of June 24, 2026. The policy establishes step-therapy requirements for branded rituximab products (Rituxan, Truxima) across nine covered indications, requiring documented intolerance or contraindication to biosimilars (Ruxience, Riabni) before approval, with exceptions for continuation of prior therapy within 365 days. Key exclusions include high-dose CLL therapies and maintenance therapy duration limits (2 years for CLL and low-grade NHL).
Action Required
By immediately: Billing and clinical teams must implement prior authorization requirements for all rituximab product claims under Humana Medicare Advantage. (1) Update billing system to require prior auth submission for CPT/HCPCS codes J9310, J9311, J9312, J9313 before claim submission. (2) For branded products (Rituxan/Truxima - J9310, J9311), configure system to require documentation of intolerance or contraindication to biosimilars (Ruxience/Riabni) UNLESS the claim is a continuation within 365 days of prior approved therapy. (3) For CLL and low-grade NHL, add validation rules to flag and deny claims exceeding 2-year maintenance therapy limit or high-dose CLL (>500mg/m²). (4) Update provider encounter forms and clinical templates to capture step-therapy status and document prior biosimilar failures. (5) Train billing staff on nine covered indications and associated criteria (diagnosis validation, age requirements for WG/MPA, concomitant methotrexate for RA, splenectomy status for ITP). (6) Configure system reminders for CD-20 positivity documentation for NHL and Hodgkin's disease claims. (7) Establish process to flag continuation-of-therapy requests to bypass step-therapy requirements. Failure to obtain required prior authorizations will result in claim denials from Humana Medicare Advantage.