MedicaidPrior AuthMedium impact
Xofigo® (radium Ra 223 dichloride) (New)
Humana·IN · Oncology, Urology, Radiation Oncology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Indiana has implemented 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 bone metastases. Billing teams must screen claims against four clinical criteria and one exclusion before processing.
Action Required
By June 30, 2026: Billing team must implement prior authorization process for Xofigo claims in Humana Medicaid Indiana. (1) Update billing system to flag all Xofigo (radium Ra 223 dichloride) claims requiring prior auth submission. (2) Create pre-service authorization checklist requiring verification of: metastatic stage IV CRPC, symptomatic bone metastases, absence of visceral metastatic disease, and concurrent bone modifying agent use (unless documented contraindication/intolerance). (3) Implement screening to deny claims if member has documented disease progression on prior Xofigo therapy. (4) Configure initial and renewal approval durations as 6 months or per clinical review. (5) Train billing and clinical staff on dosage calculation requirements and bone marrow suppression monitoring thresholds (ANC ≥1.5 x10⁹/L, platelets ≥100 x10⁹/L, hemoglobin ≥10 g/dL before first dose; subsequent doses require ANC ≥1 x10⁹/L, platelets ≥50 x10⁹/L). (6) Reference www.humana.com/PAL for current provider claim codes. Failure to obtain prior authorization will result in claim denials.