Summary
Humana Medicaid–Florida established a new prior authorization policy effective October 28, 2026, for rituximab products (Ruxience, Riabni, Truxima, and generics). The policy covers nine disease categories—including chronic lymphocytic leukemia, immune thrombocytopenic purpura, non-Hodgkin's lymphoma, Hodgkin's lymphoma, rheumatoid arthritis, Waldenstrom's macroglobulinemia, post-transplant lymphoproliferative disorder, vasculitis, and pemphigus vulgaris—plus all other medically accepted uses. Prior authorization is now required before dispensing; claims without it will be denied.
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What to do
Action · 7 steps
01Effective immediately (October 28, 2026).
02Billing team must obtain prior authorization from Humana Medicaid–Florida before any rituximab product (Ruxience, Riabni, Truxima) claim is submitted.
03Update prior auth workflows and tracking to flag all rituximab prescriptions for affected members; confirm each authorization is in place and note the member's specific diagnosis and treatment duration to match policy criteria.
04Update charge entry or claim submission systems to prevent claims from going out without documented prior auth approval—claims without authorization will be denied.
05Tell providers and clinical staff that rituximab now requires prior auth; share the policy's listed indications and exclusion criteria (e.g., CLL maintenance >2 years, DLBCL maintenance therapy).
06For members seeking rituximab off-label or for medically accepted uses not listed above, submit prior auth requests noting the indication and supporting literature; Humana will review under the 'All medically accepted uses' category.
07Watch for approval letters and renewal notices; resubmit renewals before the member's plan year ends or as Humana directs.
Codes mentioned
J9310J9311
Original notice
Rituximab Products (New)
mcp.humana.com · Always check the source before changing claims.
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