MedicaidPrior AuthHigh impact
Nivolumab products (Opdivo, Opdivo Qvantig) (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Ohio Medicaid has implemented a new Prior Authorization policy for Nivolumab products (Opdivo, Opdivo Qvantig) effective September 1, 2026, covering 19 cancer indications. The policy establishes specific clinical criteria for approval across melanoma, renal cell carcinoma, lung cancer, lymphoma, head/neck cancer, and other malignancies, with common exclusions for disease progression on anti-PD-1/PD-L1 therapy. All requests require prior authorization with 6-month approval and renewal cycles.
Action Required
By September 1, 2026: Billing team must implement prior authorization requirements for all Opdivo and Opdivo Qvantig claims submitted to Humana Ohio Medicaid. Update billing software to require prior auth submission before claims are sent, incorporating the 19 covered indications and clinical criteria listed in the policy. Providers must document diagnosis, treatment regimen (monotherapy vs. combination), and relevant clinical history to support medical necessity. For melanoma adjuvant treatment, ensure documentation that total treatment duration does not exceed one year. For all indications, verify members have no prior disease progression on anti-PD-1/PD-L1 therapies. Front desk staff should flag Opdivo/Qvantig prescriptions for Ohio Medicaid members and route to billing for prior auth initiation before dispensing. Failure to obtain prior authorization will result in claim denials by Humana.