Medicare AdvantagePrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
May 24, 2023
We identified it
Aug 13, 2026
Summary
Humana revised its prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy for Merkel cell carcinoma and anal squamous cell carcinoma. The policy clarifies coverage criteria, treatment combinations, exclusions (including prior anti-PD-1/PD-L1 therapy failure), and approval durations (6 months initial/renewal for both indications). Billing teams must ensure all Zynyz claims include prior authorization and meet the specified clinical criteria before submission.
Action Required
REQUIREMENTS: Immediately (effective ongoing from May 24, 2023): Billing team must implement prior authorization requirement for all Zynyz (retifanlimab-dlwr) claims across Medicare Advantage, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina lines of business. Before submitting any Zynyz claim: (1) Verify member has diagnosis of either recurrent locally advanced/metastatic Merkel cell carcinoma (monotherapy only) OR inoperable locally recurrent/metastatic squamous cell carcinoma of anal canal (first-line with carboplatin/paclitaxel OR post-platinum progression/intolerance); (2) Confirm member does NOT have prior disease progression on anti-PD-1/PD-L1 therapy (pembrolizumab, nivolumab, etc.); (3) For anal carcinoma first-line therapy, verify total treatment duration will not exceed 12 months; (4) Route claim through Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL for medical billing requests; (5) Update billing system workflows and provider encounter templates to mandate prior auth verification before claim submission. Consequences: Claims submitted without prior authorization approval or failing to meet clinical criteria will be denied.