MedicaidPrior AuthMedium impact
Xofigo® (radium Ra 223 dichloride) (Revised)
Humana·FL, KY, SC · Oncology, Urology·Medicaid
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Xofigo (radium Ra 223 dichloride) prior authorization policy effective April 22, 2026, for Medicaid members in Florida, Kentucky, and South Carolina. The policy maintains strict eligibility criteria requiring metastatic castration-resistant prostate cancer with symptomatic bone metastases, no visceral disease, and concurrent bone modifying agent use. Prior authorization remains required with 6-month approval/renewal cycles.
Action Required
By April 22, 2026: Billing and prior authorization teams must verify this is the current version in the Humana system (policy was revised from original 1/1/2023 effective date). For Medicaid members in FL, KY, and SC requesting Xofigo: (1) Confirm all four approval criteria are met before submitting prior auth requests—particularly verify absence of visceral metastatic disease and concurrent bone modifying agent use; (2) Submit initial prior auth requests for 6-month approval periods; (3) Flag patients for renewal prior auth 6 months after approval; (4) Document that any denials based on Exclusion #1 (prior disease progression on Xofigo) are applied correctly. Update internal prior auth submission templates to include checklist for the four criteria. Failure to obtain prior authorization will result in claim denial. Note: Do not rely on printed copies of this policy—verify online version before each submission.