MedicaidPrior AuthMedium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 21, 2026
Summary
This is a revised Humana Medicaid (Indiana) 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 mandates that patients meet strict criteria including relapsed/refractory disease status, at least four prior lines of therapy (including specific drug classes), and single-agent use only. Claims will be denied if patients have prior disease progression on BCMA-directed therapies.
Action Required
By November 1, 2025: Billing and clinical teams must implement prior authorization requirements for all Elrexfio claims submitted to Humana Indiana Medicaid. (1) Update billing system to flag Elrexfio (elranatamab-bcmm) claims as requiring prior authorization before submission. (2) Oncology providers must document in patient records: diagnosis of multiple myeloma, relapsed/refractory status, confirmation of at least four prior lines of therapy including proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody, and confirmation of single-agent use only. (3) Front desk/authorization staff must screen for exclusion criteria—specifically any prior disease progression on BCMA-directed CD3 T-cell engager regimens, which will result in denial. (4) Include REMS program enrollment verification in prior auth submission (Elrexfio is only available through restricted REMS program). (5) Update claim submission procedures to reference CMS-recognized compendia for medical necessity justification. Failure to obtain prior authorization will result in claim denials. Contact Humana PAL at www.humana.com/PAL for specific medical billing codes and preauthorization procedures.