Medicare AdvantagePrior AuthMedium impact
Imlygic (talimogene laherparepvec) (Revised)
Humana·FL, KY, SC · Oncology, Dermatology·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
This is a revised Imlygic (talimogene laherparepvec) prior authorization policy effective January 1, 2020, with a revision date of June 24, 2026. The policy applies to Medicare and Medicaid (Florida, Kentucky, South Carolina) and establishes clear clinical criteria for coverage, including specific melanoma diagnoses, age requirements (18+), application method (intralesional injection), and four exclusion criteria. Billing teams must ensure prior authorization is obtained before dispensing this therapy and verify member eligibility against the defined criteria.
Action Required
Before dispensing Imlygic (talimogene laherparepvec): (1) Billing/Prior Auth team must verify all THREE approval criteria are met: member has unresectable Stage III melanoma with in-transit metastases, local/satellite recurrence, or distant metastatic disease; Imlygic will be administered as intralesional therapy into visible/palpable lesions; member is age 18+. (2) Screen for ALL FOUR exclusions: immunocompromised status, pregnancy, prior disease progression on Imlygic, or concomitant anti-PD-1/PD-L1 agents (nivolumab, pembrolizumab, atezolizumab, avelumab). (3) Submit prior authorization request with clinical documentation supporting melanoma diagnosis and treatment plan. (4) Initial approvals valid for 6 months; renewals also valid for 6 months or as determined by clinical review. (5) Update internal prior auth checklist and EMR templates to flag exclusion criteria. Claims will be DENIED without documented prior authorization approval.