Medicare AdvantagePrior AuthHigh impact
Yervoy® (ipilimumab) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 2, 2026
Summary
Humana revised its Yervoy (ipilimumab) prior authorization policy effective January 1, 2025, with updates through June 24, 2026. The policy covers seven cancer indications (melanoma, renal cell carcinoma, MSI-H/dMMR colorectal cancer, hepatocellular carcinoma, NSCLC first-line, malignant pleural mesothelioma, and esophageal squamous cell carcinoma) with specific criteria for initial approval and renewal, including performance status requirements, combination therapy requirements for most indications, and disease progression exclusions. The policy applies to Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina.
Action Required
By January 1, 2025, the billing team must implement the following changes: (1) Update billing software to require prior authorization for all Yervoy (J9228) claims across Medicare Advantage, Traditional Medicare, and the three specified Medicaid programs (FL, KY, SC); (2) Configure the system to validate that claims meet the specific criteria for each indication (melanoma, RCC, MSI-H colorectal cancer, HCC, NSCLC, mesothelioma, or esophageal cancer) before submission; (3) Ensure prior auth requests capture ECOG performance status (0-2 required) and verify appropriate combination therapy requirements (e.g., nivolumab for RCC, colorectal cancer, HCC, mesothelioma, and esophageal cancer); (4) For melanoma indications, verify member is Yervoy-naïve and validate induction regimen completion (four cycles within 16 weeks) for renewal requests; (5) For NSCLC first-line, confirm PD-L1 status documentation and, for Medicare Part B, verify medical necessity if Libtayo cannot be used; (6) Flag and exclude any claims with disease progression on adjuvant therapy (melanoma) or previous anti-CTLA-4 combinations (colorectal, HCC); (7) Update encounter forms and provider alerts to include these criteria; (8) Train coding and authorization staff on the seven covered indications and their specific requirements. Claims submitted without valid prior authorization will be denied. Reference the policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a56a5c6.