Traditional MedicarePrior AuthLow impact
Bavencio® (avelumab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2019
We identified it
Aug 12, 2026
Summary
This is a routine revision (dated July 22, 2026) to Humana's Bavencio (avelumab) prior authorization policy for three Medicaid states (FL, KY, SC) plus Medicare. The policy maintains existing coverage criteria for four cancer indications: advanced/metastatic renal cell carcinoma (with axitinib), metastatic Merkel cell carcinoma (adults and pediatrics 12+), and locally advanced/metastatic urothelial cancer. No substantive coverage changes are documented—this appears to be a periodic policy refresh with updated prescribing information reference (June 2025) and clarification that progressive disease off-therapy does not meet exclusion criteria.
Action Required
No immediate billing workflow changes required. Billing and clinical teams should verify this is the current active policy version by cross-referencing Humana's online policy portal (as stated in document). If your practice submits Bavencio claims for these indications, confirm prior authorization protocols remain unchanged: (1) Renal cell carcinoma requests must document combination therapy with axitinib; (2) Merkel cell carcinoma requests must document metastatic disease and age eligibility (pediatric cases require age 12+); (3) Urothelial cancer requests must document qualifying therapy line or disease progression timing. Continue to deny or request additional information from providers if members have documented disease progression while on or after PD-1/PD-L1 therapies (pembrolizumab, nivolumab, atezolizumab, durvalumab). Approval duration remains 6 months with renewal available.