Medicare AdvantagePrior AuthMedium impact
Empliciti (elotuzumab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Empliciti (elotuzumab) prior authorization policy effective February 25, 2026, clarifying coverage criteria for multiple myeloma treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires prior authorization and specifies that coverage is limited to patients with disease progression after 1-3 prior lines of therapy (with lenalidomide/dexamethasone or bortezomib/dexamethasone combinations) or at least 2 prior therapies including lenalidomide and proteasome inhibitors (with pomalidomide/dexamethasone). Billing teams must ensure all Empliciti requests meet these updated clinical criteria before claim submission.
Action Required
By February 25, 2026: Billing team and prior authorization staff must update internal policies and verification protocols to enforce the revised Empliciti coverage criteria. 1) Confirm all Empliciti (elotuzumab/J9329) claims are accompanied by prior authorization before billing. 2) Verify patient meets BOTH Criteria #1 (multiple myeloma diagnosis) AND Criteria #2 (appropriate disease progression and combination therapy regimen). 3) Document the specific prior therapy line count and combination therapy details on all authorization requests. 4) Flag claims where disease progression occurred while on Empliciti—these do not qualify for coverage. 5) Update encounter forms and order entry systems to require specification of prior therapy count and combination regimen. 6) Train providers on the two distinct pathways: 1-3 prior lines + lenalidomide/dex or bortezomib/dex, versus 2+ prior therapies (including lenalidomide + proteasome inhibitor) + pomalidomide/dex. Failure to obtain updated prior authorization or billing claims that do not meet criteria will result in claim denials.