MedicaidPrior AuthMedium impact
Talvey (talquetamab) (Revised)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jul 23, 2026
Summary
This is a revised Humana Medicaid (Ohio) prior authorization policy for Talvey (talquetamab), a bispecific T-cell engager for relapsed/refractory multiple myeloma. The policy requires members to have received at least four prior lines of therapy (including specific drug classes) and be using Talvey as a single agent. Prior authorization is required before coverage, with denials if disease progression occurs on therapy or if experimental/investigational use criteria are not met.
Action Required
Before November 1, 2025: Billing and clinical teams must implement prior authorization workflow for Talvey (talquetamab) claims in the Humana Medicaid Ohio line of business. (1) Update billing system to flag all Talvey requests requiring prior auth submission. (2) Develop authorization checklist requiring verification of: diagnosis (multiple myeloma), relapsed/refractory status, documentation of at least 4 prior lines of therapy including proteasome inhibitor, immunomodulatory agent, and anti-CD38 monoclonal antibody, and confirmation of single-agent use. (3) Train providers and staff to attach supporting documentation (treatment history, pathology, prior therapy records) with each prior auth request. (4) Establish monitoring protocol post-approval to track for disease progression (exclusion trigger for continued coverage). (5) Verify member enrollment in the Tecvayli and Talvey REMS program before approval. Claims submitted without prior authorization or missing required documentation will be denied. This policy is effective immediately upon the November 1, 2025 date for all Ohio Medicaid members.