Medicare AdvantagePrior AuthHigh impact
Yervoy (ipilimumab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Yervoy (ipilimumab) prior authorization policy effective January 1, 2025, with updates finalized June 25, 2025. The policy applies to Medicare and Medicaid (Florida, Kentucky, South Carolina) and establishes prior authorization requirements across seven cancer indications, including melanoma, renal cell carcinoma, colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer. Key requirements include ECOG performance status 0-2, Yervoy naïveté for initial approvals, and combination therapy mandates for most non-melanoma indications.
Action Required
By June 25, 2025, billing team must immediately implement the following: (1) Update billing system to require prior authorization for all Yervoy (ipilimumab) claims across the seven listed cancer indications for Medicare and Medicaid plans in FL, KY, and SC; (2) Configure system to enforce ECOG performance status documentation (0-2 required) in all prior auth requests; (3) Add validation rules to ensure Yervoy naïveté is documented for initial approvals and to prevent approval if member has prior Yervoy exposure; (4) For melanoma cases, implement logic to require documentation of either unresectable/metastatic disease OR adjuvant treatment status with lymph node involvement >1mm; (5) For RCC, colorectal cancer, hepatocellular carcinoma, mesothelioma, and esophageal cancer cases, configure system to mandate concurrent Opdivo (nivolumab) use and document combination therapy rationale; (6) For NSCLC first-line, implement step therapy requiring documentation of PD-L1 status and medical reason why Libtayo cannot be used for Medicare Part B requests; (7) Add exclusion logic to deny renewal if disease progression occurs on adjuvant therapy (melanoma) or prior anti-CTLA4 combinations (colorectal, hepatocellular); (8) Set approval duration to 4 months maximum (four cycles per authorization) for all indications; (9) Update prior authorization forms and encounter templates to capture required clinical criteria; (10) Train billing, authorization, and coding staff on new requirements. Failure to obtain prior authorization will result in claim denials for all Yervoy administration claims.