Medicare AdvantagePrior AuthMedium impact
Elzonris™ (tagraxofusp-erzs) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jan 1, 2023
We identified it
Aug 12, 2026
Summary
Humana revised its prior authorization policy for Elzonris™ (tagraxofusp-erzs) effective January 28, 2026, for treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) across Medicare and three Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains three coverage criteria: confirmed BPDCN diagnosis per WHO classification, inpatient capability for the first complete course plus 24-hour observation, and patient age 2 years or older. Prior authorization is required with initial and renewal approvals valid for 6 months.
Action Required
By February 28, 2026: Billing team must update prior authorization workflows to ensure all Elzonris claims include the three required coverage criteria in PA submissions. Verify member age is 2+ years, confirm inpatient setting capability documentation, and validate WHO-classified BPDCN diagnosis before claim submission. Update claim denial protocols to flag missing criteria. Front desk staff should alert providers that Elzonris requires PA and cannot be prescribed in outpatient-only settings for initial therapy. Reference the revised policy dated 1/28/2026 at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5a1364 for Florida, Kentucky, and South Carolina Medicaid members and Medicare beneficiaries. Claims submitted without PA or missing required documentation will be denied.