Summary
This is a historical policy document (published 2026-02-01, discovered 2026-10-06) establishing a new Erbitux (cetuximab) pharmacy prior authorization policy for Ohio Medicaid members. The policy became effective February 1, 2026, and covers four cancer indications with specific molecular mutation criteria and combination therapy requirements. Billing teams should verify current applicability with Humana's online policy portal, as this 8-month-old policy may have been updated or superseded.
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What to do
Action · 4 steps
01Already effective as of February 1, 2026 (8 months prior to analysis date of 2026-10-06): Verify current applicability of this Ohio Medicaid Erbitux prior authorization policy by consulting Humana's online Medical and Pharmacy Coverage Policies portal at www.humana.com/PAL.
02Billing team should confirm whether this policy remains in effect and has not been superseded or revised.
03If applicable, ensure that all Erbitux claims for Ohio Medicaid members include documentation of: (1) specific cancer diagnosis and molecular mutation status (BRAF V600E, KRAS G12C, wild-type RAS, or head/neck squamous cell); (2) required prior systemic treatments where applicable; (3) prescribed combination therapy regimen; and (4) absence of exclusion criteria (prior disease progression on Vectibix or Erbitux, or unknown RAS mutation status).
04Prior authorization is mandatory for all covered indications—claims submitted without documented medical necessity meeting stated criteria will require denial or rework.
Codes mentioned
J9033
Original notice
Erbitux (cetuximab) (New)
mcp.humana.com · Always check the source before changing claims.
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