MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (New)
Humana·OH · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy, effective October 1, 2025. Coverage is limited to two cancer indications: recurrent locally advanced or metastatic Merkel cell carcinoma (as monotherapy), and inoperable locally recurrent or metastatic squamous cell carcinoma of the anal canal (as first-line combination therapy or second-line monotherapy). Prior authorization is required for all uses, with initial and renewal approvals valid for 6 months.
Action Required
By September 15, 2025: Billing and clinical teams must establish prior authorization workflows for Zynyz (retifanlimab-dlwr) in the billing system. Before October 1, 2025: (1) Providers must obtain prior authorization before dispensing Zynyz for any patient; (2) Billing staff must verify eligibility and PA status before submitting claims; (3) Update encounter forms and order entry systems to flag this drug as requiring PA. Implement controls to block claims without active prior authorization. Document diagnosis (Merkel cell carcinoma or SCAC) and treatment plan (monotherapy for MCC, or combination/sequential therapy for SCAC) on all PA requests. Claims submitted without documented prior authorization will be denied. Note: Patients with prior disease progression on anti-PD-1/PD-L1 therapy or first-line SCAC treatment exceeding 12 months are excluded from coverage.