Medicare AdvantagePrior AuthHigh impact
Bortezomib products (Velcade and Bortezomib for injection) (Revised)
Humana·KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for bortezomib products (Velcade and generic bortezomib for injection) effective January 1, 2022, with the most recent revision dated February 25, 2026. The policy covers three indications: mantle cell lymphoma, multiple myeloma, and Waldenström's macroglobulinemia, all requiring prior authorization. A key exclusion applies across all three indications: members who have experienced disease progression while on a bortezomib-containing regimen may not receive approval. This is a recent update (1 day old) affecting Medicaid programs in Kentucky and South Carolina, plus Medicare.
Action Required
REQUIREMENTS: By March 10, 2026 (within 2 weeks of revision date), the billing team must implement the following: (1) Update prior authorization system to require PA for all bortezomib products (Velcade, Boruzu, bortezomib for injection in all formulations) for Kentucky and South Carolina Medicaid members and Medicare members. (2) Configure system to flag and deny any requests for members with documented disease progression on prior bortezomib regimen across all three indications. (3) For Waldenström's macroglobulinemia cases, ensure system verifies three treatment criteria are met: primary/relapsed/progressive disease status, appropriate therapy type (monotherapy, with dexamethasone, or with rituximab), and no prior progression on bortezomib. (4) Update prior authorization request templates and provider-facing documentation to reflect the disease progression exclusion. (5) Train billing and clinical review staff on the specific criteria for each indication. (6) For Multiple Myeloma first-line therapy, ensure providers document platelet count ≥70,000 and ANC ≥1,000 before processing. Claims submitted without prior authorization or that violate exclusion criteria will be denied.