MedicaidPrior AuthMedium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·OH · Oncology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Summary
Humana Medicaid (Ohio) has established a new prior authorization requirement for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager indicated for extensive-stage small cell lung cancer with disease progression after platinum-based chemotherapy. Coverage requires prior auth approval for initial and renewal periods, with specific clinical criteria and exclusions based on treatment history and disease response.
Action Required
By July 1, 2026: Billing and clinical teams must implement prior authorization process for Imdelltra (tarlatamab-dlle) claims for Humana Medicaid Ohio members. (1) Configure billing system to flag all Imdelltra claims for mandatory prior auth before submission. (2) Clinical staff must verify member meets both clinical criteria: (a) diagnosis of extensive-stage SCLC, and (b) disease progression on or after platinum-based chemotherapy. (3) Deny or hold claims where member has experienced disease progression while already on Imdelltra (exclusion criterion). (4) Set approval duration to initial plan year with renewal through clinical review. (5) Ensure prescribers are aware of black box warnings for cytokine release syndrome (CRS) and neurologic toxicity (ICANS), and that step-up dosing schedule and 22-24 hour monitoring requirements on Cycle 1 Day 1 and Day 8 are documented before prior auth approval. (6) Update encounter forms and EMR templates to prompt providers for required documentation. Failure to obtain prior authorization will result in claim denial. Reference Humana PAL portal (www.humana.com/PAL) for applicable procedure codes.