MedicaidPrior AuthHigh impact
Nivolumab products (Opdivo, Opdivo Qvantig) (New)
Humana·LA · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Louisiana Medicaid has established a new prior authorization pharmacy coverage policy for Nivolumab products (Opdivo, Opdivo Qvantig) effective September 1, 2026, covering 17 cancer indications including melanoma, renal cell carcinoma, NSCLC, Hodgkin lymphoma, and others. The policy requires prior authorization for all covered indications with specific clinical criteria and exclusions (including disease progression on prior anti-PD-1/PD-L1 therapy). Initial and renewal approvals are valid for 6 months or as determined through clinical review.
Action Required
By September 1, 2026: Billing team and pharmacy staff must immediately implement prior authorization requirements for Nivolumab products (Opdivo IV and Opdivo Qvantig SC) for all Louisiana Medicaid members. Update billing software to flag claims requiring prior auth and establish workflow to verify coverage eligibility against 17 listed indications before dispensing. Providers must document: (1) specific cancer diagnosis and stage, (2) prior treatment history (especially prior anti-PD-1/PD-L1 therapy—if present, claim will be denied), (3) clinical criteria met per indication (e.g., PD-L1 expression status for NSCLC first-line, prior anti-angiogenic therapy for RCC subsequent therapy, treatment duration limits for adjuvant melanoma), and (4) combination therapy details if applicable. Front desk staff should collect updated treatment history at check-in. Pharmacy must verify each authorization has 6-month approval duration before dispensing. Failure to obtain prior authorization will result in claim denials for Louisiana Medicaid members.