MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (New)
Humana·IN · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicaid (Indiana) has implemented a new prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy for treating Merkel cell carcinoma and anal squamous cell carcinoma. The policy establishes specific clinical criteria for approval, treatment duration limits (6-month initial/renewal periods, maximum 12 months for first-line anal cancer therapy), and exclusions for patients with prior anti-PD-1/PD-L1 treatment failure. All Zynyz claims require prior authorization before dispensing.
Action Required
By September 30, 2025: Billing and clinical teams must implement prior authorization procedures for all Zynyz (retifanlimab-dlwr) claims for Indiana Medicaid members. (1) Update billing system to flag all Zynyz claims for mandatory prior auth submission before pharmacy dispensing. (2) Create prior auth request templates that capture: diagnosis (Merkel cell carcinoma or anal SCAC), disease stage (metastatic/locally advanced/locally recurrent/inoperable), treatment line (monotherapy vs. first-line combination vs. salvage), and prior anti-PD-1/PD-L1 treatment history. (3) Train clinical staff and providers that claims will be DENIED without prior authorization approval. (4) Establish tracking for 6-month approval periods and renewal requirements. (5) Document all exclusion criteria (prior PD-1/PD-L1 progression, >12 months first-line duration for anal cancer) in prior auth decision logic. (6) Confirm member eligibility for Indiana Medicaid coverage before submission. Claims submitted without prior authorization will be denied by Humana.