Medicare AdvantagePrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana updated its prior authorization policy for Zynyz (retifanlimab-dlwr) effective August 27, 2025, covering two cancer indications: Merkel cell carcinoma and anal squamous cell carcinoma. The policy now specifies approval duration of 6 months for initial and renewal periods, establishes clear eligibility criteria including monotherapy use for MCC and combination or sequential therapy options for anal carcinoma, and includes a critical exclusion for patients with prior anti-PD-1/PD-L1 therapy progression. Billing teams must implement prior authorization requirements before requesting claims for this specialty oncology drug.
Action Required
By August 27, 2025: Billing and Prior Authorization teams must implement the following changes: (1) Establish prior authorization workflow in billing system for all Zynyz (retifanlimab-dlwr) requests across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina plans; (2) Configure system to require documentation of diagnosis (recurrent locally advanced/metastatic MCC OR inoperable locally recurrent/metastatic squamous cell carcinoma of anal canal); (3) For MCC cases: verify monotherapy designation and set initial approval duration to 6 months; (4) For anal carcinoma cases: verify either first-line combination therapy (with carboplatin/paclitaxel followed by monotherapy) OR second-line monotherapy after platinum progression/intolerance, and set initial approval duration to 6 months; (5) Configure system to flag and DENY requests if patient has documented disease progression on prior anti-PD-1/PD-L1 therapy; (6) For first-line anal carcinoma: configure system to enforce maximum 12-month treatment duration limit; (7) Train oncology providers and front-desk staff to initiate prior authorization requests before treatment initiation; (8) Update patient financial counseling scripts to indicate Zynyz requires prior auth approval. Prior authorization approval is required for all covered indications—claims submitted without prior approval will be denied.