MedicaidPrior AuthMedium impact
Padcev (enfortumab vedotin-ejfv) (New)
Humana·IN · Oncology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid (Indiana) has established a new prior authorization policy for Padcev (enfortumab vedotin-ejfv), effective July 1, 2026. The policy covers two cancer indications: locally advanced/metastatic urothelial cancer and muscle-invasive bladder cancer, with specific clinical criteria for approval. Billing teams must implement prior authorization requirements before claims submission and ensure providers document all required treatment history and eligibility criteria.
Action Required
Before July 1, 2026: Billing team must implement prior authorization requirements in claims processing system for Padcev (J9119) for Indiana Medicaid members. Update encounter forms and billing workflows to require providers to submit documentation of: (1) cancer diagnosis (locally advanced/metastatic urothelial cancer OR muscle-invasive bladder cancer), (2) prior treatment history (platinum-containing chemotherapy and/or PD-1/PD-L1 inhibitor exposure), (3) cisplatin eligibility status with specific comorbidity data (CrCl, performance status, hearing loss, peripheral neuropathy, NYHA class), and (4) confirmation of combination therapy with pembrolizumab if applicable. Establish prior authorization submission process requiring clinical evidence before claim adjudication. Flag all J9119 claims for Indiana Medicaid requiring prior auth approval before payment. Communicate requirements to oncology providers and infusion centers. Claims submitted without prior authorization approval will be denied.