MedicaidPrior AuthMedium impact
Xofigo® (radium Ra 223 dichloride) (New)
Humana·LA · Oncology, Urology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Louisiana is implementing a new prior authorization policy for Xofigo (radium Ra 223 dichloride), effective July 1, 2026. All claims for this radiotherapeutic drug require prior authorization with approval durations of 6 months initially and at renewal. The policy establishes strict eligibility criteria: metastatic castration-resistant prostate cancer with symptomatic bone metastases, no visceral disease, and concurrent bone-modifying agent use unless contraindicated.
Action Required
By June 15, 2026: Billing team must implement prior authorization requirement for all Xofigo (radium Ra 223 dichloride) claims in the billing system for Louisiana Medicaid members. Create a clinical checklist to verify all four criteria are met before submission: (1) metastatic stage IV CRPC diagnosis, (2) symptomatic bone metastases documentation, (3) absence of visceral metastatic disease, and (4) concurrent bone-modifying agent use with documentation of any contraindication/intolerance. Providers must submit prior authorization requests at least 5 business days before treatment initiation. Configure system to flag any claims showing prior disease progression on Xofigo for rejection. Set 6-month renewal reminders in tracking system. Communicate with oncology providers regarding new lab value requirements (ANC ≥1.5 x10⁹/L, platelets ≥100 x10⁹/L, hemoglobin ≥10 g/dL before first dose; ANC ≥1 x10⁹/L and platelets ≥50 x10⁹/L before subsequent doses) and the need to obtain prior authorization before each treatment cycle. Failure to obtain prior authorization will result in claim denials.