MedicaidPrior AuthMedium impact
Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Opdualag (nivolumab and relatlimab-rmbw) effective January 1, 2023, with updates as of March 25, 2026. The policy requires prior authorization for this combination immunotherapy in patients 12+ years with unresectable or metastatic melanoma as monotherapy. Key exclusions include disease progression on prior anti-PD-1/PD-L1 combination therapy and concurrent use with BRAF/MEK inhibitors. Initial and renewal authorizations are approved for 6 months or as determined through clinical review.
Action Required
By March 25, 2026 (revision date): Billing team must implement prior authorization requirements for all Opdualag claims for Louisiana Medicaid members. Action items: (1) Update billing system to require prior auth for Opdualag intravenous solution before claims are submitted; (2) Create or revise encounter form templates to capture: patient age (must be 12+), melanoma diagnosis confirmation (unresectable or metastatic), confirmation of monotherapy use, and verification that patient has NOT progressed on prior anti-PD-1/PD-L1 combination therapy; (3) Ensure providers document absence of concurrent BRAF/MEK inhibitor use (Zelboraf, Tafinlar, Mekinist, Cotellic); (4) Configure system to flag claims if member has disease progression history on prior immunotherapy combination for manual review; (5) Set authorization duration to 6-month increments for both initial and renewal approvals; (6) Train billing staff on exclusion criteria and document requirements. Providers must submit prior authorization requests through Humana's PAL system (www.humana.com/PAL) before administering Opdualag. Claims submitted without prior authorization or failing to meet eligibility criteria will be denied. This applies ONLY to Louisiana Medicaid members.