MedicaidPrior AuthHigh impact
Imfinzi (durvalumab)
Humana·LA · Oncology, Hematology, Pulmonology·Medicaid
Effective date
May 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Louisiana Medicaid has established a new prior authorization policy for Imfinzi (durvalumab) effective May 1, 2026, covering nine cancer indications. The policy requires prior authorization for all uses, with specific clinical criteria and exclusions for each indication (e.g., disease progression on prior anti-PD-1/PD-L1 therapy). Billing and clinical teams must verify member eligibility, confirm diagnosis matches policy criteria, and submit prior authorization requests before dispensing.
Action Required
By May 1, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization system to require PA submission for all Imfinzi (durvalumab) claims with indication verification against the nine covered diagnoses; (2) For each claim, verify the member meets ALL stated criteria for their specific cancer type (e.g., biliary tract cancer requires gemcitabine + cisplatin combination; endometrial cancer requires dMMR status documentation; NSCLC perioperative requires tumor >4cm and/or node positive AND no EGFR mutations/ALK rearrangements); (3) Screen for exclusions before approval (most exclusions relate to disease progression on prior anti-PD-1/PD-L1 therapy); (4) Update encounter templates and provider documentation requirements to capture required clinical data (tumor staging, genomic testing results, treatment combinations, surgery dates for cycle counting where applicable); (5) Set approval durations in system: initial 6 months or as clinically reviewed, renewal 6 months or as clinically reviewed; (6) For perioperative NSCLC and gastric/GEJC indications, ensure billing team monitors cycle limits (max 12 cycles adjuvant); for unresectable NSCLC, monitor 12-month therapy maximum. Failure to obtain prior authorization before claim submission will result in claim denial.