Medicare AdvantagePrior AuthMedium impact
Padcev (enfortumab vedotin-ejfv) (Revised)
Humana·FL, KY, SC · Oncology, Urology·Medicaid
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Padcev (enfortumab vedotin-ejfv) prior authorization policy effective April 22, 2026, affecting coverage for locally advanced/metastatic urothelial cancer and muscle-invasive bladder cancer across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The policy clarifies approval criteria for monotherapy, combination therapy with pembrolizumab, and cisplatin-ineligibility documentation requirements. Billing teams must verify patient eligibility against updated criteria before claim submission to avoid denials.
Action Required
By April 22, 2026: Billing and prior authorization teams must update internal policy references and verification protocols to reflect the revised Padcev coverage criteria. Specifically: (1) Verify all Padcev claims require prior authorization; (2) Confirm patient meets one of three pathways: monotherapy with prior platinum + PD-1/PD-L1 treatment, monotherapy with prior lines of therapy and cisplatin-ineligibility, or combination with pembrolizumab; (3) For muscle-invasive bladder cancer cases, verify patient is receiving Padcev with pembrolizumab before/after cystectomy AND is cisplatin-ineligible; (4) Document cisplatin-ineligibility comorbidities (CrCl <60, PS ≥2, hearing loss ≥25dB, grade ≥2 neuropathy, or NYHA ≥3) in patient record before submission; (5) Update prior authorization request forms to reference the April 22, 2026 revision date. Providers must alert oncology and urology departments to the updated medical necessity requirements. Claims submitted without proper prior authorization or incomplete cisplatin-ineligibility documentation will be denied. Verify this is the current policy version on Humana's website before implementation.