Medicare AdvantagePrior AuthMedium impact
Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Opdualag (nivolumab and relatlimab-rmbw) prior authorization policy effective March 25, 2026. The policy applies to Medicare, Medicaid (Florida, Kentucky, South Carolina) and requires prior authorization for this immune checkpoint inhibitor combination therapy in patients 12+ years old with unresectable or metastatic melanoma. Key exclusions include prior disease progression on anti-PD-1/PD-L1 combination therapy and concurrent use with BRAF/MEK inhibitors. Initial and renewal approvals are valid for 6 months or as determined through clinical review.
Action Required
By March 25, 2026: Billing and prior authorization teams must implement the following: (1) Update billing system to flag all Opdualag claims for mandatory prior authorization before submission; (2) Providers must document patient age (≥12 years) and diagnosis of unresectable or metastatic melanoma in all claims; (3) Prior auth requests must verify exclusion criteria—specifically confirm no prior disease progression on anti-PD-1/PD-L1 combination therapy (e.g., nivolumab + ipilimumab) and no concomitant BRAF/MEK inhibitor use (vemurafenib, dabrafenib, trametinib, cobimetinib); (4) Set internal tracking for 6-month approval windows for both initial and renewal authorizations; (5) Deny or hold claims that fail to meet the three approval criteria or contain any exclusion. Failure to obtain prior auth will result in claim denials for all affected Medicaid and Medicare members in FL, KY, and SC.