Medicare AdvantagePrior AuthMedium impact
Jelmyto (mitomycin) (Revised)
Humana·FL, KY, SC · Urology, Oncology·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Jelmyto (mitomycin) pharmacy coverage policy effective November 26, 2025, for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy establishes prior authorization requirements for intra-pyelocalyceal mitomycin treatment of low-grade upper tract urothelial cancer (LG-UTUC), with specific approval criteria and exclusions. This is a routine policy revision with no apparent changes to coverage scope, but billing teams must ensure prior authorization is obtained before claims are submitted.
Action Required
By December 26, 2025: Billing team must implement prior authorization requirements for all Jelmyto (mitomycin) pyelocalyceal solution claims in the affected states (FL, KY, SC) and Medicare plans. Update billing system to flag Jelmyto claims for mandatory prior auth before submission. Verify member eligibility meets criteria: (1) noninvasive low-grade upper tract urothelial cancer diagnosis, (2) non-metastatic disease. Exclude approval if bladder or urinary tract perforation is documented. Route all requests through Humana's Preauthorization and Notification List (PAL) portal at www.humana.com/PAL using applicable medical and procedural codes. Notify providers that claims submitted without prior authorization will be denied. Update internal workflows to reference the revised policy document dated 11/26/2025 rather than older versions.