Temodar (temozolomide) (Revised)

EFFECTIVE IMMEDIATELY: Billing and clinical teams must implement prior authorization requirements for all Temodar (temozolomide) prescriptions under Humana Medicare Advantage plans before processing claims. (1) Update billing system to flag all Temodar capsule, Temodar intravenous solution, and generic temozolomide capsule orders for mandatory prior auth. (2) Verify each claim meets one of the approved indications: GBM/anaplastic astrocytoma (newly diagnosed, maintenance, or recurrent), anaplastic gliomas, low-grade gliomas with prior carmustine/lomustine/procarbazine failure, Ewing's sarcoma with irinotecan, unresectable/recurrent melanoma, pancreatic/lung/thymus neuroendocrine tumors, mycosis fungoides/Sezary syndrome, primary CNS lymphoma, or soft tissue sarcoma. (3) Confirm member does not have dacarbazine hypersensitivity (documented exclusion). (4) For low-grade gliomas specifically, verify prior disease progression on carmustine, lomustine, or procarbazine regimens. (5) Confirm appropriate drug combinations where required (bevacizumab for GBM/anaplastic glioma recurrent disease; irinotecan for Ewing's sarcoma; capecitabine for pancreatic neuroendocrine tumors; methotrexate + rituximab or rituximab monotherapy for CNS lymphoma). (6) Submit prior authorization requests to Humana before dispensing; approval covers initial plan year duration or as clinically determined. Failure to obtain prior authorization will result in claim denials. Providers and pharmacy teams must collaborate to ensure documentation supports medical necessity per CMS-recognized compendia or peer-reviewed literature.