MedicaidPrior AuthMedium impact
Jemperli (dostarlimab-gxly)
Humana·OH · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 6, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Jemperli (dostarlimab-gxly), an immunotherapy drug for endometrial cancer and dMMR solid tumors. The policy effective November 1, 2025 defines three coverage pathways: (1) frontline endometrial cancer in combination with carboplatin/paclitaxel followed by maintenance, (2) second-line or beyond dMMR endometrial cancer as monotherapy, and (3) unresectable/metastatic dMMR solid tumors as monotherapy. All approvals require prior authorization and exclude patients with prior anti-PD-1/PD-L1 therapy progression.
Action Required
By October 31, 2025: Billing and clinical team must implement prior authorization workflow for Jemperli (dostarlimab-gxly) intravenous solution in the billing system and clinical documentation templates. (1) Billing team: Configure system to require prior auth for all Jemperli requests for Medicaid Ohio members; (2) Clinical/Coding team: Ensure all claims include documentation of: diagnosis (primary advanced/recurrent endometrial cancer, dMMR status, or dMMR solid tumors), treatment line/indication, prior therapy history (including any prior anti-PD-1/PD-L1 agents and outcome), and dosing regimen (combination vs. monotherapy); (3) Prior auth staff: Review authorization requests against the three clinical pathways and verify exclusion criteria (disease progression on prior anti-PD-1/PD-L1 therapy). Establish communication protocol with GlaxoSmithKline and oncology providers for expedited reviews. Failure to obtain prior authorization will result in claim denials for Ohio Medicaid members.