MedicaidPrior AuthMedium impact
Imjudo (tremelimumab-actl)
Humana·OH · Oncology, Pulmonology·Medicaid
Effective date
Dec 1, 2025
We identified it
Aug 12, 2026
Summary
Humana Medicaid (Ohio) has established a new prior authorization policy for Imjudo (tremelimumab-actl) effective December 1, 2025. The policy covers two cancer indications: unresectable hepatocellular carcinoma (must be used with Imfinzi/durvalumab) and metastatic/advanced/recurrent NSCLC without sensitizing genomic aberrations (must be used with Imfinzi and platinum-based chemotherapy). Prior authorization is required for both initial (6 months) and renewal periods, with automatic denial if the patient has experienced disease progression on Imjudo.
Action Required
By December 1, 2025: Billing team must implement prior authorization workflow for Imjudo (tremelimumab-actl) pharmacy claims for Ohio Medicaid members. (1) Update billing system to flag all Imjudo claims for mandatory prior authorization review. (2) Providers must verify at the time of prescribing that the member meets ALL criteria: for HCC—unresectable diagnosis AND concurrent use with Imfinzi (durvalumab); for NSCLC—metastatic/advanced/recurrent diagnosis AND absence of EGFR/ALK mutations AND concurrent use with Imfinzi and platinum-based chemotherapy. (3) Check member records for exclusion: deny authorization if member has prior disease progression on Imjudo. (4) Set authorization duration tracking for initial 6-month approval periods and establish renewal processes. (5) Route all Imjudo PA requests through Humana Medicaid portal (www.humana.com/PAL) using applicable pharmacy codes. (6) Communicate with oncology and pulmonology providers in your network about documentation requirements. Failure to obtain prior authorization will result in claim denials; claims submitted without meeting criteria will be rejected.