Medicare AdvantagePrior AuthMedium impact
Jemperli (dostarlimab-gxly) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Sep 24, 2025
We identified it
Aug 6, 2026
Summary
Humana revised its Jemperli (dostarlimab-gxly) prior authorization policy effective September 24, 2025, affecting coverage for endometrial cancer (frontline and 2nd line+) and dMMR solid tumors across Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains three distinct approval pathways with specific clinical criteria and adds explicit exclusions for patients with disease progression on prior anti-PD-1/PD-L1 therapy.
Action Required
By September 24, 2025: Billing team must implement prior authorization requirements for Jemperli IV administration in the billing system across all affected payers (Medicare, Medicaid-FL, Medicaid-KY, Medicaid-SC). Update PA workflows to route requests through three distinct pathways: (1) frontline endometrial cancer requiring combination therapy documentation, (2) 2nd line+ endometrial cancer with dMMR confirmation and prior platinum progression, and (3) dMMR solid tumors with documented metastatic/unresectable status and prior therapy failure. Verify all PA requests include documentation that patient has NOT progressed on prior anti-PD-1/PD-L1 therapy (nivolumab, pembrolizumab, etc.), as this is an automatic exclusion. Claims submitted without prior authorization or missing exclusion criteria verification will be denied. Providers must confirm genetic testing for dMMR status per Humana's Genetic Testing policy before PA submission for applicable indications.