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

Pemetrexed Products (Revised)

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

Summary

Humana Indiana Medicaid has issued a revised prior authorization policy for pemetrexed products (effective November 1, 2025, revised September 23, 2026) covering treatment of malignant pleural mesothelioma and non-squamous non-small cell lung cancer. The policy specifies approval criteria including diagnosis confirmation, treatment regimen requirements, and renal function exclusions (CrCl < 45 ml/minute). Billing teams must ensure prior authorization is obtained before claims are submitted for any pemetrexed administration under this plan.

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What to do

by Nov 1, 2025 · 7 steps
01Billing and clinical teams must implement prior authorization requirements for all pemetrexed products (J9305, J9304) for Indiana Medicaid members.
02Update billing system to flag all pemetrexed claims requiring prior authorization before submission.
03Clinical staff must verify member meets one of two approved diagnoses: malignant pleural mesothelioma OR non-squamous NSCLC with documented treatment regimen (cisplatin/carboplatin combination, bevacizumab-based regimen, single agent, or pembrolizumab first-line combination therapy).
04Verify renal function: obtain recent creatinine clearance labs and confirm CrCl ≥ 45 ml/minute—DENY coverage for CrCl < 45 ml/minute.
05For NSCLC cases, confirm member does NOT have squamous cell histology.
06Submit prior authorization request through Humana's PAL (Preauthorization and Notification List) at www.humana.com/PAL before dispensing.
07Update provider encounter forms and templates to include diagnosis, treatment regimen, and renal function documentation fields.
If missed: Failure to obtain prior authorization will result in claim denials.

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 policiesIN policy changesOncologyPulmonologyHematologyCode J9305Code J9304

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