MedicaidPrior AuthMedium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·LA · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jul 23, 2026
Summary
Humana Louisiana Medicaid is establishing a new prior authorization requirement for Vyloy (zolbetuximab-clzb), a cancer immunotherapy drug used to treat HER2-negative gastric and gastroesophageal junction adenocarcinoma. Coverage requires documented CLDN18.2 positivity and use as first-line therapy in combination with fluoropyrimidine and platinum chemotherapy. Prior authorization must be obtained before dispensing; initial and renewal approvals are valid for 6 months.
Action Required
By October 1, 2025: Billing team and pharmacy staff must implement prior authorization workflow for Vyloy (zolbetuximab-clzb) claims submitted to Humana Louisiana Medicaid. (1) Create or update billing system to flag all Vyloy requests for mandatory prior auth before claim submission. (2) Establish verification process to confirm member meets all three coverage criteria: diagnosis of locally advanced unresectable or metastatic HER2-negative gastric/GEJ adenocarcinoma, CLDN18.2-positive status (≥75% tumor cells with moderate-to-strong membranous staining on FDA-approved test), and use as first-line combination therapy with fluoropyrimidine and platinum chemotherapy. (3) Coordinate with oncology providers to ensure CLDN18.2 test results and HER2 status documentation are attached to prior auth requests. (4) Set approval tracking for 6-month renewal cycles. (5) Deny or hold any claims lacking prior authorization. Access www.humana.com/PAL for claim code specifics. Failure to obtain prior auth will result in claim denials.