Medicare AdvantagePrior AuthMedium impact
Bavencio® (avelumab) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jul 23, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Bavencio (avelumab) prior authorization policy effective July 23, 2025. The policy maintains coverage for four oncology indications (renal cell carcinoma, Merkel cell carcinoma in adults and pediatrics 12+, and urothelial cancer) with specific treatment line requirements and exclusions. Key exclusion: members with disease progression on/after PD-1/PD-L1 therapy are not approved. Prior auth approval duration remains 6 months initial and renewal.
Action Required
By July 23, 2025: Billing team must verify this is the current Bavencio policy in the Humana system and update prior authorization workflows accordingly. For any pending or new Bavencio claims: (1) Confirm member has one of four covered diagnoses (advanced/metastatic RCC with Inlyta; metastatic MCC; locally advanced/metastatic UC); (2) Verify treatment line matches policy requirements (RCC requires first-line combination; MCC requires monotherapy; UC requires second+ line, disease progression within 12 months of chemo, or maintenance after first-line platinum chemo); (3) Confirm member has NOT experienced disease progression while on or following PD-1/PD-L1 inhibitors (Keytruda, Opdivo, Tecentriq, Imfinzi); (4) Submit prior auth request with clinical documentation supporting indication and treatment line. Do NOT process claims without prior authorization approval. Claims submitted without meeting all criteria or with prior PD-L1 progression will be denied.