MedicaidPrior AuthMedium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 21, 2026
Summary
This is a revised Medicaid (Ohio) prior authorization policy for Elrexfio (elranatamab-bcmm), a bispecific BCMA-directed CD3 T-cell engager for relapsed/refractory multiple myeloma. The policy requires prior authorization and establishes four approval criteria: confirmed multiple myeloma diagnosis, relapsed/refractory disease, receipt of at least four prior therapy lines (including specific agent classes), and single-agent use. One exclusion applies: prior disease progression on a BCMA-directed bispecific regimen. The policy emphasizes black box warnings for cytokine release syndrome and neurologic toxicity, requiring step-up dosing and patient monitoring.
Action Required
Before November 1, 2025: Billing team must implement prior authorization (PA) workflow for all Elrexfio claims submitted under Medicaid Ohio plans. Add to authorization system: (1) verification of multiple myeloma diagnosis; (2) confirmation of relapsed/refractory disease status; (3) documentation of at least four prior therapy lines including proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody; (4) confirmation single-agent use (NOT in combination); (5) screening for prior disease progression on BCMA-directed bispecific regimens (automatic denial if present). Update PA request forms to require oncology provider attestation of these criteria. Route all Elrexfio claims to medical review before payment. Contact Humana at www.humana.com/PAL for specific claim codes and submission procedures. Claims submitted without completed PA or failing to meet criteria will be denied. Train providers and front desk staff that Elrexfio requires PA before dispensing—no exceptions for Medicaid Ohio members.