Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)

By May 27, 2026: Billing and prior authorization teams must implement the following: 1. Update billing system templates and prior authorization workflows to require documentation of: - Confirmed metastatic castration-resistant prostate cancer (mCRPC) diagnosis - PSMA-positive disease confirmation via 68GA-PSMA-11 or F-18 piflufolastat imaging (document imaging type and results) - Prior ARPI therapy failure or intolerance (with specific drug names and dates) - Either: (a) clinical determination that patient is appropriate to delay taxane-based chemotherapy, OR (b) documented prior taxane-based chemotherapy with drug names and treatment dates - Confirmation that patient has NOT received prior Pluvicto (maximum 6 doses lifetime at 6-week intervals) - Absence of disease progression while on Pluvicto (if applicable) 2. Prior authorization team must flag any requests for more than 6 total lifetime doses and deny accordingly. 3. Billing team must verify all Pluvicto claims include prior authorization approval before submission to Humana for Medicare Advantage and applicable Medicaid plans (FL, KY, SC, VA). 4. Update encounter forms and EMR templates to prompt providers for PSMA imaging documentation and ARPI/taxane therapy history. 5. Train front-desk and billing staff that Pluvicto claims submitted without complete prior authorization documentation will be denied. Responsible parties: Prior authorization team (primary), billing team (claims verification), clinical staff (documentation support).