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Pemetrexed Products (Revised)
Act
by Sep 24, 2025, the billing and prior authorization team must
Effective date
Sep 24, 2025
Identified
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.
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What to do
by Sep 24, 2025, the billing and prior authorization team must · 7 steps
01Update billing system to reflect the September 24, 2025 revision of the Pemetrexed Products policy.
02Ensure 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).
03For 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.
04Train prior authorization reviewers to reject claims for squamous cell NSCLC or CrCl < 45 ml/min with the appropriate exclusion codes.
05Update encounter templates and claim submission requirements to capture required clinical criteria before authorization.
06Verify all online policy resources are current by visiting Humana's policy portal.
07Communicate policy changes to oncology providers to ensure proper documentation at time of service.
If missed: Failure to implement prior authorization will result in claim denials and potential payment recoupture.
Codes mentioned
J9305Q2189
Original notice
Pemetrexed Products (Revised)
mcp.humana.com · Always check the source before changing claims.
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