MedicaidPrior AuthMedium impact
Palonosetron IV (Aloxi generics) (Revised)
Humana·SC · Oncology, Anesthesiology, Pediatrics +1 more·Medicaid
Effective date
Nov 26, 2025
We identified it
Jul 2, 2026
Summary
This is a revised prior authorization policy for Palonosetron IV (Aloxi generics) effective November 26, 2025, covering four indications: adult CINV prophylaxis (ages 17+), pediatric CINV prophylaxis (ages 1 month to <17 years), PONV prophylaxis (≤24 hours post-surgery), and PONV treatment (ages 19+). Key criteria include emetogenic chemotherapy classification per NCCN guidelines, age requirements, and specific clinical scenarios. Approval is granted for plan year duration for CINV and 3-month periods for PONV.
Action Required
By November 26, 2025: Billing and prior authorization teams must implement prior authorization requirements for palonosetron IV (HCPCS code J2469) for all Medicaid South Carolina members. Update billing system to require verification of: (1) indication type (CINV or PONV); (2) member age (17+ for adult CINV, 1 month to <17 for pediatric CINV, 19+ for PONV treatment); (3) for CINV: confirmation of LEC/MEC/HEC per NCCN guidelines or refractory CINV status; (4) for pediatric CINV: confirmation of MEC/HEC only (LEC not covered); (5) for PONV prophylaxis: documentation that use will not exceed 24 hours post-surgery; (6) for PONV treatment: confirmation member received non-5-HT3 prophylactic agent or no prophylaxis. Update prior authorization forms to capture these clinical criteria. Train prior authorization staff on approval duration (plan year for CINV; 3 months for PONV). Claims submitted without required prior authorization will be denied. Verify this is the current version on www.humana.com/PAL before processing requests.