MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (New)
Humana·IN · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Aug 13, 2026
Summary
Humana Medicaid Indiana has established a new prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy for Merkel cell carcinoma and anal squamous cell carcinoma. The policy requires prior authorization before dispensing, with specific clinical criteria for each indication and defined approval durations of 6 months for initial and renewal periods.
Action Required
By October 1, 2025: Billing team must implement prior authorization requirements for Zynyz (retifanlimab-dlwr) claims for Indiana Medicaid members. Update billing software to: (1) flag all Zynyz claims for prior authorization before claim submission, (2) require documentation of diagnosis (recurrent locally advanced or metastatic Merkel cell carcinoma, OR inoperable locally recurrent or metastatic squamous cell carcinoma of anal canal), (3) verify treatment approach matches policy criteria (monotherapy for MCC; first-line with carboplatin/paclitaxel followed by monotherapy OR single-agent after progression for anal cancer), and (4) document that member has NOT progressed on prior anti-PD-1/PD-L1 therapy. Oncology providers must submit prior authorization requests with clinical documentation before treatment initiation. Set approval tracking for 6-month renewal intervals. Claims submitted without prior authorization will be denied. Reference policy URL: https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5847fe. Verify this is current version on Humana website before implementation.