MedicaidPrior AuthHigh impact
Yervoy® (ipilimumab) (New)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicaid Indiana has implemented 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. The policy establishes specific clinical criteria, approval durations (initial and renewal), and exclusions for each indication. Billing teams must implement prior authorization requirements before this date to ensure claims are not denied.
Action Required
By August 15, 2026: Billing team must implement prior authorization workflow in billing system for Yervoy (ipilimumab) HCPCS code J9228 for all Indiana Medicaid claims. Update system to require clinical documentation verifying: (1) one of seven approved cancer indications; (2) for melanoma—naïve status and ECOG 0-2 performance status; (3) for combination therapies (RCC, colorectal, hepatocellular, mesothelioma, esophageal)—concurrent administration of Opdivo or appropriate chemotherapy; (4) PD-L1 testing results for NSCLC first-line. Configure system to flag exclusions including prior anti-CTLA4 therapy, concomitant BRAF/MEK inhibitors (for melanoma), and disease progression on prior Yervoy. Set approval duration limits to 4 months maximum (four cycles) per authorization. Add authorization requirements to provider order entry forms and encounter documentation templates. Train billers on renewal criteria including 3+ month disease control requirement for melanoma reinduction and 3-year treatment limit for adjuvant melanoma. Communicate workflow changes to oncology providers. Failure to obtain prior authorization before claim submission will result in claim denials from Humana Indiana Medicaid.