MedicaidPrior AuthMedium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (New)
Humana·IN · Oncology, Urology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 4, 2026
Summary
Humana Indiana Medicaid is establishing a new prior authorization requirement for Pluvicto (lutetium Lu 177 vipivotide tetraxetan), a radioligand therapeutic for PSMA-positive metastatic castration-resistant prostate cancer (mCRPC). Effective August 1, 2026, all Pluvicto claims require prior authorization and must meet specific clinical criteria including PSMA-positive disease confirmation, prior ARPI therapy failure, and appropriate candidate status relative to taxane-based chemotherapy. Maximum benefit is limited to 6 doses at intervals of at least 6 weeks per plan year.
Action Required
By July 15, 2026: Billing team and providers must implement the following steps: (1) Update billing software and prior authorization workflows to require pre-authorization for all Pluvicto (lutetium Lu 177 vipivotide tetraxetan) intravenous solution claims for Indiana Medicaid members; (2) Configure system alerts to enforce the four approval criteria at point of billing: confirmation of mCRPC diagnosis, PSMA-positive imaging documentation (68GA-PSMA-11 or F-18 piflufolastat), prior ARPI therapy failure with either taxane delay appropriateness or prior taxane exposure, and prior dose tracking (maximum 6 doses per plan year); (3) Create or update prior authorization submission template to require supporting clinical documentation including diagnostic imaging reports and treatment history; (4) Train billing staff and providers on the new policy, particularly the PSMA-positive disease definition and ARPI/taxane therapy requirements; (5) Establish tracking mechanism for dose limits to prevent billing beyond 6 doses per plan year; (6) Flag any claims showing disease progression on Pluvicto for denial per exclusion criteria. Failure to obtain prior authorization or provide required clinical documentation will result in claim denials. Reference Humana's PAL (Preauthorization and Notification List) at www.humana.com/PAL for applicable medical coding information.