MedicaidPrior AuthMedium impact
Padcev (enfortumab vedotin-ejfv) (New)
Humana·LA · Oncology, Urology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Louisiana has established a new prior authorization policy for Padcev (enfortumab vedotin-ejfv) effective July 1, 2026. The policy covers two indications: locally advanced or metastatic urothelial cancer (as monotherapy or combination therapy) and muscle-invasive bladder cancer (in combination with pembrolizumab). Prior authorization is required for all Padcev administration in these covered scenarios.
Action Required
By July 1, 2026: Billing and clinical teams must implement prior authorization requirements for all Padcev (enfortumab vedotin-ejfv) claims submitted to Humana Medicaid Louisiana. (1) Update billing system to flag all Padcev intravenous solution claims for mandatory prior auth submission before claim processing. (2) Providers must verify patient meets one of two clinical pathways before ordering: either locally advanced/metastatic urothelial cancer with specified prior treatment history OR muscle-invasive bladder cancer with pembrolizumab and cisplatin-ineligibility documentation. (3) Front office staff must attach clinical documentation at time of prior auth request demonstrating: prior platinum chemotherapy and PD-1/PD-L1 inhibitor use (if monotherapy), OR cisplatin-ineligibility criteria (CrCl <60, PS ≥2, hearing loss ≥25dB, grade ≥2 neuropathy, NYHA class ≥3). (4) Create clinical checklist for oncology practices to confirm eligibility before submitting claims. Claims submitted without prior authorization will be denied. Approval duration is plan year or as determined through clinical review.