Medicare AdvantagePrior AuthHigh impact
Levoleucovorin products (Revised)
Humana·KY, SC, VA · Oncology, Hematology, Palliative Care·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
This is a revised Humana prior authorization policy for levoleucovorin products (Khapzory, Fusilev, generic levoleucovorin) effective immediately for Medicare and Medicaid plans in Kentucky, South Carolina, and Virginia. The policy clarifies coverage criteria for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer. All requests require prior authorization and documented failure or intolerance of leucovorin calcium before levoleucovorin approval.
Action Required
By September 24, 2025: Billing and prior authorization team must implement the following: (1) Update billing system to require prior authorization for all levoleucovorin products (J0640, J0641, Khapzory, Fusilev) for Kentucky, South Carolina, and Virginia Medicaid and Medicare members; (2) Configure system to verify member meets ONE of three clinical pathways: osteosarcoma with high-dose methotrexate, methotrexate toxicity, or advanced metastatic colorectal cancer with 5-FU; (3) Require documentation that member was previously treated with leucovorin calcium AND experienced documented side effects (either lack of efficacy or formulation intolerance); (4) Screen for exclusion: pernicious anemia or B12-deficiency megaloblastic anemia; (5) Update prior authorization forms and submission protocols to capture serum methotrexate levels and dosing guidance per clinical situation table; (6) Train providers on three dose adjustment scenarios (normal elimination, delayed late, delayed early/acute renal injury). Notify ordering providers in Kentucky, South Carolina, and Virginia that claims will be DENIED without prior authorization. Route all requests through Humana's PAL system (www.humana.com/PAL) for medical benefit inquiries.