Medicare AdvantagePrior AuthMedium impact
Monjuvi® (tafasitamab-cxix) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Monjuvi (tafasitamab-cxix) prior authorization policy effective August 27, 2025, clarifying coverage criteria for two lymphoma indications: relapsed/refractory DLBCL (in combination with lenalidomide, max 12 cycles, then single agent) and relapsed/refractory follicular lymphoma (in combination with lenalidomide and rituximab, max 12 cycles total). The policy applies to Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina plans with specific clinical eligibility requirements and exclusions.
Action Required
By August 27, 2025: Billing and prior authorization teams must implement this revised policy in claims processing and authorization systems. (1) Update PA request forms to require documentation of: diagnosis (DLBCL not otherwise specified OR follicular lymphoma), relapsed/refractory disease status, ASCT ineligibility (for DLBCL), and combination therapy details (lenalidomide ± rituximab). (2) Configure billing system to flag claims exceeding 12 treatment cycles for follicular lymphoma indications as exclusions requiring medical director review. (3) Ensure prior auth review screens document that members with prior anti-CD19 therapy progression are excluded from DLBCL coverage. (4) Train authorization staff on the distinction between DLBCL criteria (3 required, 1 exclusion) and follicular lymphoma criteria (3 required, 1 exclusion). (5) Update provider communication materials for oncology practices in FL, KY, and SC. Failure to implement may result in claim denials or improper authorizations.