Medicare AdvantagePrior AuthMedium impact
Thalomid® (thalidomide) (Revised)
Humana·Oncology, Hematology, Infectious Disease·Medicare Advantage
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Thalomid (thalidomide) prior authorization policy effective February 25, 2026, maintaining coverage for three indications (ENL, Multiple Myeloma, Waldenstrom's Macroglobulinemia) with consistent 6-month approval durations. No coverage criteria changes were made, but billing teams must ensure all new and renewal Thalomid requests include prior authorization and verify patient S.T.E.P.S.® program enrollment before dispensing.
Action Required
Before February 25, 2026: (1) Billing and pharmacy staff must verify all Thalomid prescriptions trigger prior authorization requests in the claims system for Medicare Advantage members. (2) Confirm patient enrollment in the FDA-mandated S.T.E.P.S.® program (System for Thalidomide Education and Prescribing Safety) before approving any Thalomid claims—claims from non-enrolled patients will be denied. (3) For ENL patients, document whether treatment is for acute manifestations OR maintenance therapy to meet coverage criteria. (4) For Multiple Myeloma and Waldenstrom's Macroglobulinemia, verify diagnosis and therapy type (primary, progressive/relapsed, or salvage) are documented. (5) Flag any claims where patient experienced disease progression while on Thalomid—these are excluded from coverage. (6) Ensure prophylactic anticoagulation is documented for multiple myeloma patients (noted in policy as recommended practice). (7) Review initial and renewal requests—both require 6-month approval durations. Providers: Enroll all patients in S.T.E.P.S.® program and document all required clinical criteria on prescriptions before submission. Failure to obtain prior authorization or confirm S.T.E.P.S.® enrollment will result in claim denials.