MedicaidPrior AuthMedium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)
Humana·LA · Oncology, Urology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 4, 2026
Summary
Humana Medicaid (Louisiana) is establishing a new prior authorization policy for Pluvicto (lutetium Lu 177 vipivotide tetraxetan), a radioligand therapeutic for PSMA-positive metastatic castration-resistant prostate cancer. Effective August 1, 2026, all Pluvicto claims require prior authorization verification of four clinical criteria plus documented PSMA-positive disease confirmation and ARPI therapy failure, with maximum coverage of 6 doses.
Action Required
By July 15, 2026: Billing team and prior authorization staff must establish a new prior authorization process in the billing system for all Pluvicto (lutetium Lu 177 vipivotide tetraxetan) claims from Louisiana Medicaid members. Create a PA checklist requiring verification of: (1) mCRPC diagnosis, (2) PSMA-positive disease documented by 68GA-PSMA-11 or F-18 piflufolastat imaging, (3) prior ARPI therapy failure AND either appropriate taxane delay or prior taxane receipt, and (4) no prior Pluvicto courses. Add exclusion check for prior disease progression on Pluvicto. Configure system to limit approvals to maximum 6 doses per plan year. Update claim submission instructions to oncology and urology providers in Louisiana. Obtain imaging documentation (PSMA diagnostic imaging results) before authorizing. Claims submitted without required prior authorization will be denied. Providers should be notified of new requirement immediately to allow adequate documentation collection time before August 1, 2026 implementation.