Medicare AdvantagePrior AuthMedium impact
Zevalin® (ibritumomab tiuxetan) (Revised)
Humana·VA · Oncology, Hematology, Pharmacy·Medicaid
Effective date
May 20, 2015
We identified it
Jun 25, 2026
Summary
Humana revised its Zevalin (ibritumomab tiuxetan) prior authorization policy for Medicaid and Medicare in Virginia, effective December 17, 2025. The policy maintains existing approval criteria for relapsed/refractory or previously untreated follicular non-Hodgkin's lymphoma with response to chemotherapy, limits coverage to 1 course per lifetime, and reinforces clinical exclusions including prior radioimmunotherapy, pediatric use, pregnancy/breastfeeding, bone marrow involvement ≥25%, and low platelet/neutrophil counts. Billing teams must ensure prior authorization is obtained before claims are submitted for this high-cost radiopharmaceutical.
Action Required
REQUIREMENTS:
- Effective immediately (policy revision dated 12/17/2025): Billing and clinical teams must verify that all Zevalin (ibritumomab tiuxetan) claims for Virginia Medicaid and Medicare members include prior authorization documentation before submission.
- Update prior authorization workflows in billing system to flag Zevalin requests and ensure they meet ALL criteria: (1) Member has relapsed/refractory low-grade/follicular NHL OR previously untreated follicular NHL with partial/complete response to first-line chemo; (2) Member has NOT received prior radioimmunotherapy with Zevalin.
- Verify exclusion criteria before authorizing: exclude members <18 years old, pregnant/breastfeeding women, those with prior hypersensitivity, altered biodistribution, platelet counts <100,000/mm³, neutrophil counts <1,500/mm³, or bone marrow involvement ≥25%.
- Set lifetime limit flag in system: approval duration is limited to 1 course per lifetime; do NOT reauthorize for same member.
- Notify providers that dosing must not exceed 32 mCi (1184 MBq) of Y-90 and must be verified before claim approval.
- Add prior authorization requirement to Virginia Medicaid and Medicare encounter templates and billing checklists.
- Failure to obtain prior authorization will result in claim denials under Humana plans.