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HumanaMedicaid · Prior Auth · Medicaid · OH · Oncology, Pulmonology, HematologyHigh impact

Pemetrexed Products (Revised)

Act
by Nov 1, 2025
Effective date
Nov 1, 2025
Identified
Sep 24, 2026

Summary

This is a revised Humana Medicaid policy (Ohio) for pemetrexed products effective November 1, 2025, establishing prior authorization requirements for malignant pleural mesothelioma and non-squamous non-small cell lung cancer. Key exclusion: patients with creatinine clearance <45 ml/minute are not approved. The policy covers multiple pemetrexed formulations and brands (Alimta, Pemfexy, Pemrydi RTU, Axtle) with specific combination therapy requirements for NSCLC.

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What to do

by Nov 1, 2025 · 6 steps
01Billing team must implement prior authorization requirements in Humana system for all pemetrexed products (Alimta, Pemfexy, Pemrydi RTU, Axtle).
02Update claim submission workflow to require: (1) diagnosis verification (malignant pleural mesothelioma OR non-squamous NSCLC), (2) renal function documentation (CrCl ≥45 ml/minute), and (3) for NSCLC cases, documentation of therapy combination type (cisplatin/carboplatin-based, bevacizumab-based, single agent, or immunotherapy combination).
03Configure billing system to auto-deny claims with CrCl <45 ml/minute.
04Update provider order forms and EMR templates to include required clinical criteria.
05Notify oncology providers of new documentation requirements.
06Claims submitted without prior authorization or missing renal clearance verification will be denied by Humana Ohio Medicaid.

Codes mentioned

J9305J9304

Original notice

Pemetrexed Products (Revised)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesOH policy changesOncologyPulmonologyHematologyCode J9305Code J9304

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