MedicaidPrior AuthHigh impact
Pemetrexed Products (Revised)
Humana·FL, KY, SC · Oncology, Palliative Care·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Pemetrexed Products prior authorization policy effective September 24, 2025, affecting coverage for pemetrexed-based chemotherapy across multiple pemetrexed formulations (Alimta, Pemfexy, Pemrydi RTU, Axtle) for malignant pleural mesothelioma and non-squamous non-small cell lung cancer. The policy maintains prior authorization requirements and renal function exclusions (CrCl < 45 ml/min) but clarifies approved treatment combinations and adds new first-line pembrolizumab-combination therapy criteria for NSCLC patients without EGFR/ALK mutations.
Action Required
By September 24, 2025, the billing and prior authorization team must: (1) Update billing system to reflect the September 24, 2025 revision of the Pemetrexed Products policy; (2) Ensure all pemetrexed claims (J9305, Q2189) for Medicaid members in Florida, Kentucky, and South Carolina require prior authorization documentation including diagnosis confirmation and renal function assessment (CrCl ≥ 45 ml/min); (3) For NSCLC cases, require documentation that treatment meets one of the four approved combinations: cisplatin/carboplatin combination, bevacizumab-containing regimen, single agent, or first-line pembrolizumab + chemotherapy for patients without EGFR/ALK aberrations; (4) Train prior authorization reviewers to reject claims for squamous cell NSCLC or CrCl < 45 ml/min with the appropriate exclusion codes; (5) Update encounter templates and claim submission requirements to capture required clinical criteria before authorization; (6) Verify all online policy resources are current by visiting Humana's policy portal; (7) Communicate policy changes to oncology providers to ensure proper documentation at time of service. Failure to implement prior authorization will result in claim denials and potential payment recoupture.