MedicaidPrior AuthHigh impact
Levoleucovorin products (Revised)
Humana·LA · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jan 1, 2023
We identified it
Aug 6, 2026
Summary
This is a revised Humana Medicaid Louisiana prior authorization policy for levoleucovorin products (Khapzory, Fusilev, and generics) effective January 1, 2023, with a revision dated September 24, 2025. The policy outlines coverage criteria for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer with 5-fluorouracil. Key requirement: prior authorization is mandatory, and coverage is only approved if the member has already failed or experienced side effects from standard leucovorin calcium therapy, necessitating a switch to levoleucovorin.
Action Required
By September 24, 2025 (policy revision date - EFFECTIVE IMMEDIATELY): (1) Billing team must update prior authorization protocols in all billing and claims systems to require mandatory prior auth submission before dispensing or billing for any levoleucovorin product (Khapzory, Fusilev, generic levoleucovorin calcium IV solution/powder). (2) Modify claim submission workflows to verify member meets ALL required criteria: for osteosarcoma—prior leucovorin calcium treatment + documented side effects requiring therapy change; for methotrexate toxicity—current toxicity symptoms + prior leucovorin calcium treatment + documented side effects; for colorectal cancer—advanced metastatic disease + 5-FU combination chemotherapy + prior leucovorin calcium treatment + documented side effects. (3) Providers and prior auth staff must screen for exclusions: reject requests for members with pernicious anemia or megaloblastic anemia secondary to B12 deficiency. (4) Update encounter templates and billing notes to capture documentation of: previous leucovorin calcium treatment dates, specific side effects experienced (efficacy failure or formulation intolerance), and clinical indication. (5) Ensure all submitted prior auth requests include serum methotrexate levels and dosing tables per policy for toxicity cases. (6) Compliance deadline: All system updates must be complete before processing any levoleucovorin claims. Failure to obtain prior authorization will result in claim denials, and improper use in patients with B12-deficiency anemias may cause patient harm.