MedicaidPrior AuthHigh impact
Yervoy® (ipilimumab) (New)
Humana·LA · Oncology, Hematology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicaid Louisiana has implemented a NEW prior authorization policy for Yervoy (ipilimumab) effective September 1, 2026, covering seven cancer indications (melanoma, RCC, MSI-H colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer). The policy establishes specific clinical criteria for initial approval and renewal, with most indications requiring combination therapy with Opdivo (nivolumab) and maximum 4-month authorization periods. Billing teams must immediately identify Yervoy claims and implement prior authorization workflows before the effective date.
Action Required
By August 31, 2026: Billing team must implement prior authorization workflow for Yervoy (ipilimumab) HCPCS code J9228 in the Humana Medicaid Louisiana plan. (1) Update billing system to flag all J9228 claims for prior auth requirement; (2) Create authorization checklist requiring documentation of: cancer diagnosis (melanoma, RCC with clear cell histology, MSI-H/dMMR colorectal cancer, hepatocellular carcinoma, NSCLC with PD-L1 status, mesothelioma, or esophageal squamous cell carcinoma), ECOG performance status 0-2, naïve status to Yervoy, and required combination therapy partner (Opdivo for all indications except melanoma monotherapy); (3) Instruct providers that initial authorizations will be approved for maximum 4 months (4 cycles) only; (4) Set renewal criteria in system to verify no disease progression on adjuvant therapy, continued ECOG 0-2 status, and total treatment duration <3 years (melanoma adjuvant); (5) Implement claim denial logic: deny any J9228 claims lacking prior authorization, claims from members with progressive disease on adjuvant therapy, claims with concomitant vemurafenib/dabrafenib/trametinib/cobimetinib, or claims showing disease progression after prior anti-CTLA4 combinations. Without these changes, all J9228 claims will be denied.