MedicaidPrior AuthHigh impact
Imfinzi (durvalumab)
Humana·OH · Oncology, Hematology, Pulmonology +1 more·Medicaid
Effective date
May 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Medicaid (Ohio) has implemented a new Prior Authorization policy for Imfinzi (durvalumab) effective May 1, 2026, covering 9 oncology indications including biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, and various lung cancers. The policy requires specific diagnostic criteria, combination therapy regimens, and disease progression exclusions for each indication. All approvals are limited to initial 6-month periods with 6-month renewals.
Action Required
By April 15, 2026: Billing team must implement prior authorization workflow for Imfinzi (durvalumab, J9173) in the billing system for all Ohio Medicaid members. Configure system to require prior auth before claim submission for the 9 covered indications. Update encounter forms and templates to capture required clinical documentation: (1) specific cancer diagnosis per policy, (2) disease stage/extent, (3) combination therapy regimen per indication, (4) genetic/biomarker testing results (EGFR/ALK status for lung cancers, dMMR status for endometrial cancer), (5) prior anti-PD-1/PD-L1 therapy history. Train providers and billing staff on exclusion criteria—particularly disease progression on prior immunotherapy which requires denial. Establish 6-month tracking system for initial and renewal authorizations. Failure to obtain prior auth will result in claim denials for all Imfinzi claims submitted for Ohio Medicaid effective May 1, 2026.