MedicaidPrior AuthMedium impact
Imjudo (tremelimumab-actl)
Humana·IN · Oncology·Medicaid
Effective date
Dec 1, 2025
We identified it
Aug 12, 2026
Summary
Humana Indiana Medicaid has established a new prior authorization policy (effective December 1, 2025) for Imjudo (tremelimumab-actl), an immunotherapy drug for hepatocellular carcinoma and non-small cell lung cancer. Coverage requires specific combination therapy protocols and prior authorization with 6-month approval/renewal periods. Claims for Imjudo without prior authorization or meeting clinical criteria will be denied.
Action Required
By December 1, 2025: (1) Billing team must update authorization workflows to require prior authorization for all Imjudo (tremelimumab-actl) claims for Indiana Medicaid members before claims submission. (2) Providers must document diagnosis of either unresectable hepatocellular carcinoma OR metastatic/advanced/recurrent NSCLC with confirmed absence of sensitizing genomic aberrations (EGFR, ALK). (3) Verify combination therapy eligibility: HCC patients must receive Imjudo WITH Imfinzi (durvalumab); NSCLC patients must receive Imjudo WITH Imfinzi AND platinum-based chemotherapy. (4) Implement tracking system for 6-month approval/renewal cycles—claims submitted after 6 months require renewed prior authorization. (5) Add exclusion check to pre-authorization review: deny coverage if member has experienced prior disease progression on Imjudo. Failure to obtain prior authorization will result in claim denials. Update billing system rules and provider order entry templates to require prior auth initiation before medication dispensing.