Medicare AdvantagePrior AuthMedium impact
Folotyn® (pralatrexate) (Revised)
Humana·FL, SC · Oncology, Hematology·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Folotyn (pralatrexate) prior authorization policy effective November 26, 2025, for Medicare, Medicaid-Florida, and Medicaid-South Carolina. The policy maintains prior authorization requirements for relapsed or refractory peripheral T-cell lymphoma (PTCL) treatment and reinforces the exclusion criterion that members experiencing disease progression while on Folotyn may not be approved for continued coverage.
Action Required
By November 26, 2025: Billing team and clinical staff must ensure all Folotyn (pralatrexate) requests include prior authorization submission for Medicare, Medicaid-Florida, and Medicaid-South Carolina members. Update billing system to flag any Folotyn claims for these plans as requiring prior auth. Verify that member documentation includes: (1) confirmation of relapsed or refractory PTCL diagnosis with specific subtype; (2) evidence that member is NOT experiencing disease progression on current Folotyn therapy; (3) confirmation of concurrent folic acid and Vitamin B12 supplementation; and (4) absence of hypersensitivity history or pregnancy/lactation without documented risk-benefit discussion. Reject or hold any Folotyn authorization requests if disease progression is documented, as approval is contraindicated. Update encounter templates and provider communication materials to reflect the November 26, 2025 revision date. Failure to obtain prior authorization will result in claim denials.