MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (Revised)
Humana·LA · Oncology·Medicaid
Effective date
Jan 1, 2026
We identified it
Aug 13, 2026
Summary
Humana Louisiana Medicaid updated its prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy. The policy covers two cancer indications: (1) monotherapy for recurrent/locally advanced/metastatic Merkel cell carcinoma, and (2) first-line combination therapy or second-line monotherapy for inoperable locally recurrent/metastatic squamous cell carcinoma of the anal canal. Key exclusion: patients with prior disease progression on anti-PD-1/PD-L1 therapy are not eligible. Prior authorization is required with initial and renewal approval periods of 6 months.
Action Required
By January 1, 2026: Billing team must establish prior authorization workflow for Zynyz (retifanlimab-dlwr) intravenous solution in the billing system. (1) Providers must submit prior auth requests documenting: (a) diagnosis of either recurrent/locally advanced/metastatic Merkel cell carcinoma OR inoperable locally recurrent/metastatic squamous cell carcinoma of the anal canal; (b) intended use (monotherapy for MCC or first-line combination vs. second-line monotherapy for SCAC); (c) no prior disease progression on anti-PD-1/PD-L1 therapy (e.g., pembrolizumab, nivolumab); (d) for first-line SCAC therapy, confirmation treatment duration will not exceed 12 months total. (2) Update encounter forms and EMR templates to prompt providers to document these criteria before submitting claims. (3) Configure billing system to flag claims for Zynyz without prior authorization approval for denial. (4) Front desk and authorization staff should be trained on the two distinct approval pathways (MCC vs. SCAC). Initial approvals are valid for 6 months; plan renewals at 6-month intervals. Failure to obtain prior authorization will result in claim denials.