MedicaidPrior AuthMedium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·OH · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jul 23, 2026
Summary
Humana Medicaid (Ohio) has implemented a new prior authorization requirement for Vyloy (zolbetuximab-clzb), a monoclonal antibody for treating HER2-negative, CLDN18.2-positive gastric and gastroesophageal junction adenocarcinoma. The drug requires prior authorization when used as first-line therapy in combination with fluoropyrimidine and platinum chemotherapy, with initial and renewal approvals valid for 6 months.
Action Required
By October 1, 2025: Billing team must implement prior authorization requirement for Vyloy (zolbetuximab-clzb) claims for Medicaid patients in Ohio. Before submitting claims, obtain prior authorization by verifying: (1) member has locally advanced unresectable or metastatic HER2-negative gastric or GEJ adenocarcinoma, (2) disease is CLDN18.2-positive per FDA-approved test, and (3) Vyloy will be used as first-line therapy combined with fluoropyrimidine and platinum chemotherapy. Reject any claims where member has experienced prior disease progression on Vyloy. Update encounter forms and billing software to flag Vyloy claims for Ohio Medicaid members and route to prior auth team. Communicate policy to oncology providers and pharmacy staff. Claims submitted without prior authorization will be denied. Track approvals for 6-month renewal requirements.