Medicare AdvantagePrior AuthMedium impact
Jemperli (dostarlimab-gxly) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Jemperli (dostarlimab-gxly) prior authorization policy effective September 24, 2025, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy covers three indications: frontline endometrial cancer (combination therapy), second-line+ endometrial cancer (monotherapy for dMMR cases), and dMMR solid tumors. A critical exclusion applies: prior disease progression on anti-PD-1/PD-L1 therapy disqualifies members. Billing teams must implement prior authorization requirements for all Jemperli claims under these plans.
Action Required
By September 24, 2025: Billing team must update prior authorization workflows in all claims systems for Humana Medicare Advantage and Medicaid plans (FL, KY, SC). For all Jemperli (dostarlimab-gxly) intravenous solution requests: (1) Verify member meets specific clinical criteria based on indication (frontline EC with combination therapy, 2nd+ line EC with dMMR status, or dMMR solid tumors); (2) Confirm member has NOT progressed on prior PD-1/PD-L1 therapy (nivolumab, pembrolizumab, etc.)—if yes, denial is appropriate; (3) Require prior authorization before claim submission; (4) Set initial approval duration to plan year for frontline EC or 6 months for 2nd+ line/solid tumors. Providers must document dMMR status via FDA-approved test for 2nd+ line and solid tumor indications. Obtain updated prescribing information (August 2024 version per policy). Claims submitted without prior authorization will be denied. Update encounter templates and billing software rules by the effective date.