MedicaidPrior AuthHigh impact
Nivolumab products (Opdivo, Opdivo Qvantig) (New)
Humana·IN · Oncology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicaid Indiana has established a new prior authorization policy for Nivolumab products (Opdivo, Opdivo Qvantig) effective September 1, 2026. This policy defines specific criteria for coverage across 16 cancer indications including melanoma, renal cell carcinoma, NSCLC, Hodgkin lymphoma, and others. All prescriptions for these products require prior authorization with initial and renewal approvals valid for 6 months or as determined through clinical review.
Action Required
By September 1, 2026: Billing and clinical teams must implement prior authorization requirement for all Nivolumab products (Opdivo, Opdivo Qvantig) for Humana Medicaid Indiana members. Update billing system to flag and require prior auth submission for HCPCS codes J9299 (Nivolumab IV) and J9301 (Nivolumab subcutaneous) before claim submission. Obtain required clinical documentation from providers including: diagnosis confirmation (specific cancer type and stage), prior treatment history, PD-L1 expression status if applicable, and confirmation of appropriate use criteria per indication. Create workflow to verify member meets all applicable criteria (e.g., stage requirements for melanoma adjuvant, prior anti-angiogenic therapy for RCC subsequent therapy, disease progression exclusions). Train providers and front-desk staff on new requirements. Claims submitted without prior authorization or failing to meet clinical criteria will be denied. Monitor for the following key exclusions across all indications: disease progression while on/after anti-PD-1/PD-L1 therapy, and for melanoma adjuvant and NSCLC neoadjuvant—treatment duration limits. Establish tracking system for 6-month renewal cycles.