MedicaidPrior AuthMedium impact
Folotyn® (pralatrexate)
Humana·IN · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jan 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Indiana Medicaid has implemented a new prior authorization policy for Folotyn® (pralatrexate) effective January 1, 2026. This injectable chemotherapy requires prior auth for relapsed or refractory peripheral T-cell lymphoma (PTCL) treatment, with automatic denial if the patient has experienced disease progression while on Folotyn. Billing teams must obtain prior authorization before dispensing and verify vitamin B12/folic acid supplementation documentation.
Action Required
By December 31, 2025: Billing and clinical teams must implement prior authorization workflow for Folotyn® (pralatrexate) in the Humana Indiana Medicaid plan. Specifically: (1) Update billing system to flag all pralatrexate claims requiring prior auth submission before dispensing; (2) Create pre-authorization checklist requiring documentation of: relapsed/refractory PTCL diagnosis (verified against NCCN Compendium), patient vitamin B12 and folic acid supplementation initiation, and absence of prior disease progression on Folotyn; (3) Train pharmacy and billing staff to deny claims if patient has documented disease progression history on pralatrexate; (4) Obtain prior authorization through Humana's PAL system (www.humana.com/PAL) before each treatment cycle; (5) Update encounter forms and EMR templates to require oncology providers to document PTCL subtype (e.g., peripheral T-cell lymphoma NOS, angioimmunoblastic, anaplastic large cell, enteropathy-associated) and treatment history. Consequence: Claims submitted without prior authorization or missing required documentation will be denied, delaying patient treatment and generating rework.