Medicare AdvantagePrior AuthMedium impact
Imjudo (tremelimumab-actl) (Revised)
Humana·FL, KY, SC · Oncology, Internal Medicine·Medicaid
Effective date
Jan 1, 2025
We identified it
Aug 12, 2026
Summary
Humana revised its prior authorization policy for Imjudo (tremelimumab-actl) effective January 1, 2025, with a revision date of October 22, 2025. The policy covers two oncology indications: unresectable hepatocellular carcinoma (in combination with Imfinzi) and metastatic NSCLC without sensitizing genomic aberrations (in triple combination with Imfinzi and platinum-based chemotherapy). Prior authorization is required for all uses, with a key exclusion for members with prior disease progression on Imjudo.
Action Required
By January 1, 2025: Billing team must implement prior authorization requirement for all Imjudo (tremelimumab-actl) claims across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. (1) Update billing system to flag all Imjudo requests for mandatory prior auth before claim submission. (2) Providers must document: for HCC cases—unresectable diagnosis AND concurrent Imfinzi therapy; for NSCLC cases—metastatic/advanced/recurrent status, absence of sensitizing genomic aberrations (EGFR, ALK), AND concurrent Imfinzi plus platinum-based chemotherapy (note: Medicare Part B requires step therapy documentation showing Libtayo cannot be used, or prior Libtayo therapy within 365 days). (3) Deny claims if member has documented disease progression on prior Imjudo therapy. (4) Set initial and renewal authorization periods at 6 months or as clinically determined. (5) Front desk staff should verify patient is on approved lines of business and in covered states before scheduling. Failure to obtain prior auth will result in claim denials. Reference clinical review documentation for Medicare Part B step therapy requirements.