Medicare AdvantagePrior AuthMedium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Nov 15, 2023
We identified it
Jul 22, 2026
Summary
This is a revised Humana 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 strict clinical criteria including diagnosis of relapsed/refractory multiple myeloma, receipt of at least four prior lines of therapy (including specific drug classes), and single-agent use only. A critical exclusion applies: members with prior disease progression on BCMA-directed bispecific regimens are not eligible.
Action Required
Before November 15, 2023 (or immediately for any Elrexfio claims submitted after that date): Billing team must implement prior authorization requirements in the billing system for Elrexfio claims across affected Medicaid state plans (Florida, Kentucky, South Carolina) and Medicare Advantage. Create or update claim submission workflows to require prior auth approval before processing. Providers must verify ALL four clinical criteria are met before requesting authorization: (1) multiple myeloma diagnosis confirmed, (2) relapsed/refractory disease status documented, (3) at least four prior lines of therapy documented including proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody, and (4) Elrexfio prescribed as single agent only. Identify and flag any claims where member has prior disease progression on BCMA-directed bispecific regimens—these will be denied. Add documentation checklist to authorization requests to capture prior treatment history and confirm exclusion criteria are not met. Failure to obtain prior authorization will result in claim denials. Route all Elrexfio prior auth requests through clinical review process per Humana guidelines.