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HumanaMedicaid · Prior Auth · Medicaid · LA · Oncology, Hematology, PharmacyHigh impact

Nivolumab products (Opdivo, Opdivo Qvantig) (New)

Act
by Sep 1, 2026
Effective date
Sep 1, 2026
Identified
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.

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What to do

by Sep 1, 2026 · 5 steps
01Billing team and pharmacy staff must immediately implement prior authorization requirements for Nivolumab products (Opdivo IV and Opdivo Qvantig SC) for all Louisiana Medicaid members.
02Update billing software to flag claims requiring prior auth and establish workflow to verify coverage eligibility against 17 listed indications before dispensing.
03Providers 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.
04Front desk staff should collect updated treatment history at check-in.
05Pharmacy must verify each authorization has 6-month approval duration before dispensing.
If missed: Failure to obtain prior authorization will result in claim denials for Louisiana Medicaid members.

Codes mentioned

J9299J9305

Original notice

Nivolumab products (Opdivo, Opdivo Qvantig) (New)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesLA policy changesOncologyHematologyPharmacyCode J9299Code J9305

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