MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (New)
Humana·LA · Oncology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Louisiana Medicaid has established a new prior authorization policy effective January 1, 2026 for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy used to treat Merkel cell carcinoma and anal squamous cell carcinoma. The policy requires prior authorization with specific clinical criteria, approval durations of 6 months for initial and renewal periods, and excludes patients with prior anti-PD-1/PD-L1 therapy progression or exceeding 12-month treatment duration for first-line anal carcinoma therapy.
Action Required
By December 15, 2025: Billing team must establish prior authorization submission workflows for Zynyz (retifanlimab-dlwr) in the billing system for Louisiana Medicaid claims. Create clinical criteria checklist in billing software requiring: (1) diagnosis confirmation (recurrent locally advanced/metastatic Merkel cell carcinoma OR inoperable locally recurrent/metastatic squamous cell carcinoma of anal canal), (2) therapy type documentation (monotherapy for MCC; first-line combination with carboplatin/paclitaxel OR post-progression single agent for SCAC), (3) exclusion screening (no prior anti-PD-1/PD-L1 disease progression; first-line SCAC duration ≤12 months). Train billing staff to flag claims for prior authorization before submission. Update encounter templates to prompt providers to document treatment line, previous therapy history, and performance status. Set calendar reminders for 6-month renewal authorization submissions. Failure to obtain prior authorization will result in claim denials.