MedicaidPrior AuthHigh impact
Imfinzi (durvalumab)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
May 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Indiana Medicaid establishes a new prior authorization policy for Imfinzi (durvalumab) covering nine cancer indications effective May 1, 2026. The policy requires prior auth approval for specific diagnoses and treatment combinations, with defined criteria and exclusions (including prior anti-PD-1/PD-L1 therapy progression). Billing teams must implement prior auth requirements in their systems and ensure claims meet all specified criteria before submission.
Action Required
By April 30, 2026: Billing team must configure EHR/billing system to require prior authorization for HCPCS code J9173 (durvalumab) for all Indiana Medicaid members. Create clinical decision support rules that verify: (1) diagnosis matches one of nine covered indications (biliary tract, endometrial, gastric/GEJC, hepatocellular carcinoma, NSCLC metastatic/perioperative/unresectable, small cell extensive/limited stage), (2) treatment regimen matches policy-specified combinations, (3) member has no history of disease progression on prior anti-PD-1/PD-L1 agents. Update prior auth submission templates to capture required clinical information. Train providers and front desk staff to obtain prior auth BEFORE dispensing Imfinzi. Implement system alerts to flag claims without active prior auth approval. Without prior auth, claims will be denied. Contact Humana at the plan-specified prior auth number before May 1, 2026 to register for electronic prior auth submission if available.