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HumanaMedicaid · Prior Auth · Medicaid · IN · Oncology, PulmonologyMedium impact

Imjudo (tremelimumab-actl) (Revised)

Act
by Dec 1, 2025
Effective date
Dec 1, 2025
Identified
Sep 23, 2026

Summary

Humana Indiana Medicaid has revised its prior authorization policy for Imjudo (tremelimumab-actl), an immunotherapy drug for hepatocellular carcinoma and non-small cell lung cancer. The policy establishes specific clinical criteria for approval, including required combination therapies and exclusions for patients with prior disease progression on the drug. Prior authorization is required for both initial (6 months) and renewal periods.

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What to do

by Dec 1, 2025 · 9 steps
01Billing and prior authorization teams must implement this policy in all systems for Humana Indiana Medicaid members.
02Update prior authorization workflows to require submission for Imjudo (J9313) claims.
03For hepatocellular carcinoma requests, verify member has unresectable HCC diagnosis AND will receive concurrent Imfinzi (durvalumab).
04For NSCLC requests, verify member has metastatic/advanced/recurrent disease WITHOUT sensitizing genomic aberrations (EGFR, ALK negative) AND will receive concurrent Imfinzi plus platinum-based chemotherapy.
05Flag claims for denial if member has documented disease progression on prior Imjudo therapy.
06Set approval duration to 6 months initially, with renewal submissions required every 6 months.
07Update provider submission forms and EMR templates to capture required clinical criteria.
08Providers and billing staff must communicate with oncology offices to ensure proper documentation of diagnosis type, disease stage, genetic testing results, and concurrent drug regimen.
09Claims submitted without proper prior authorization or missing required clinical criteria will be denied.

Codes mentioned

J9313

Original notice

Imjudo (tremelimumab-actl) (Revised)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesIN policy changesOncologyPulmonologyCode J9313

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