Medicare AdvantagePrior AuthMedium impact
Provenge® (sipuleucel-T) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
This is a revised Provenge® (sipuleucel-T) prior authorization policy effective December 17, 2025, for Medicaid programs in Florida, Kentucky, and South Carolina, plus Medicare. The policy maintains coverage for asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer with strict eligibility criteria (ECOG 0-1, no visceral disease) and explicitly excludes concomitant use with Zytiga or Xtandi due to insufficient safety/efficacy evidence.
Action Required
By December 17, 2025: Billing and prior authorization teams must update system workflows to enforce Provenge prior authorization requirements for eligible Medicaid (FL, KY, SC) and Medicare patients. Ensure prior auth templates include verification of: (1) asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer diagnosis, (2) ECOG performance status 0-1 documentation, (3) absence of visceral metastases (lung, liver, brain), and (4) confirmation that patient is NOT concurrently receiving Zytiga (abiraterone acetate) or Xtandi (enzalutamide). Deny claims for Stage I-III prostate cancer and concomitant use scenarios. Set approval duration tracking for 6-month intervals per initial and renewal guidelines. Communicate policy changes to oncology providers and infusion centers. Failure to obtain prior authorization will result in claim denials.