MedicaidPrior AuthMedium impact
Xofigo® (radium Ra 223 dichloride) (New)
Humana·OH · Oncology, Urology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Xofigo (radium Ra 223 dichloride) effective July 1, 2026. The policy requires prior authorization for this radiotherapeutic drug used to treat metastatic castration-resistant prostate cancer with symptomatic bone metastases. Approval is limited to 6-month intervals and requires documentation that members meet all four clinical criteria and have no exclusions.
Action Required
By June 15, 2026: Billing and clinical teams must implement prior authorization workflow for Xofigo. (1) Billing team: Update billing system to flag all Xofigo claims (radium Ra 223 dichloride intravenous solution) for Medicaid Ohio members as requiring prior authorization before claim submission. (2) Providers and clinical staff: Create checklist to verify ALL four approval criteria are met before treatment: (a) metastatic castration-resistant prostate cancer (stage IV CRPC), (b) symptomatic bone metastases, (c) no visceral metastatic disease, and (d) concurrent bone modifying agent use (unless documented contraindication/intolerance). (3) Document in patient record confirmation of these criteria and check for Exclusion #1 (prior disease progression on Xofigo). (4) Prior authorization staff: Obtain clinical review before first dose; set approval expiration to 6 months from approval date and establish renewal reminder system. (5) Billing team: Verify baseline labs are obtained and documented before treatment (ANC ≥1.5 x10⁹/L, platelets ≥100 x10⁹/L, hemoglobin ≥10 g/dL). Without prior authorization, Medicaid claims will be denied.