MedicaidPrior AuthHigh impact
Yervoy® (ipilimumab) (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicaid Ohio has released a NEW prior authorization policy for Yervoy (ipilimumab) effective September 1, 2026, covering seven cancer indications including melanoma, renal cell carcinoma, colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer. All Yervoy requests require prior authorization with specific clinical criteria, performance status requirements (ECOG 0-2), and approval durations capped at 4 months per authorization cycle.
Action Required
By September 1, 2026: Billing team must implement prior authorization requirement for all Yervoy (ipilimumab) claims under Humana Medicaid Ohio. Update billing system and EMR to require prior auth submission before claims are processed. Providers must document: (1) cancer diagnosis and indication from approved list, (2) ECOG performance status (0-2), (3) treatment plan specifics (induction vs. adjuvant vs. combination therapy), and (4) for continuation requests, response to prior treatment (stable disease, partial response, or complete response for >3 months). Front desk staff must verify Medicaid eligibility under Ohio plan before scheduling. Establish internal workflow to submit prior auth requests with required clinical documentation. Set calendar reminders for renewal submissions at 4-month intervals. Claims submitted without prior authorization will be denied. For combination therapies (e.g., Yervoy + Opdivo), ensure both drugs are submitted on same prior auth request.