Medicare AdvantagePrior AuthMedium impact
Gleostine (lomustine) (Revised)
Humana·Oncology, Hematology, Radiation Oncology·Medicare Advantage
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
Humana has revised its Gleostine (lomustine) prior authorization policy effective January 1, 2020, with the most recent revision dated December 17, 2025. This Medicare Advantage pharmacy policy maintains prior authorization requirements for lomustine use in brain tumors and Hodgkin lymphoma, with specific approval criteria and exclusions that billing teams must verify before claim submission. The policy clarifies that prior authorization is required for all Gleostine dispensing, and claims lacking proper authorization will be denied.
Action Required
By December 31, 2025: Billing and prior authorization teams must update their systems to reflect the revised Gleostine (lomustine) policy. Specifically: (1) Ensure all Gleostine/lomustine requests trigger mandatory prior authorization workflow in billing software; (2) Verify that PA requests include confirmation of diagnosis (primary/metastatic brain tumor OR Hodgkin lymphoma with disease progression post-chemotherapy); (3) Confirm coverage criteria are met before processing claims—for brain tumors: verify surgical/radiotherapy completion OR recurrent/progressive disease documented; for Hodgkin lymphoma: verify disease progression after initial chemotherapy AND use as combination chemotherapy component; (4) Apply exclusion rule: deny or escalate any request where member has experienced disease progression while already on Gleostine; (5) Update PA denial templates to reference the December 17, 2025 revision date if criteria are not met. Pharmacy staff should reference this policy when receiving prescriptions. Failure to obtain proper prior authorization will result in claim denials under Medicare Advantage plans.