Medicare AdvantagePrior AuthMedium impact
Folotyn® (pralatrexate) (Revised)
Humana·FL, SC · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Nov 26, 2025
We identified it
Aug 12, 2026
Summary
Humana revised its Folotyn (pralatrexate) prior authorization policy effective November 26, 2025, for Medicare, Medicaid-Florida, and Medicaid-South Carolina. The policy maintains prior authorization requirements for relapsed or refractory peripheral T-cell lymphoma (PTCL) treatment and explicitly excludes members who have experienced disease progression while on Folotyn. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility for this high-cost injectable chemotherapy.
Action Required
By November 26, 2025: Billing and pharmacy teams must implement the revised prior authorization requirements for Folotyn (pralatrexate). (1) Update billing system to flag all Folotyn claims for prior authorization review before dispensing. (2) Verify in member records whether they have previously experienced disease progression on Folotyn—if yes, do not submit for authorization as claims will be denied. (3) Ensure all Folotyn requests include documentation confirming: member has relapsed or refractory PTCL diagnosis (specify subtype: PTCL-NOS, angioimmunoblastic, anaplastic large cell, or enteropathy-associated); member is receiving concurrent folic acid and Vitamin B12 supplementation; member is not pregnant/lactating or risks have been counseled. (4) Pharmacy staff should verify member has received folic acid and B12 supplementation before dispensing. (5) Update prior authorization submission templates to include disease progression history screening. Failure to obtain prior authorization will result in claim denials. Contact Humana PAL at www.humana.com/PAL for current authorization codes.