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HumanaMedicaid · Prior Auth · Medicaid · LA · Oncology, HematologyHigh impact

Imjudo (tremelimumab-actl) (Revised)

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

Summary

Humana revised its Imjudo (tremelimumab-actl) prior authorization policy for Louisiana Medicaid effective December 1, 2025. The policy covers two indications: unresectable hepatocellular carcinoma (must be combined with Imfinzi/durvalumab) and metastatic NSCLC without sensitizing genomic aberrations (must be combined with Imfinzi and platinum-based chemotherapy). Prior authorization is required for all uses, with initial and renewal approvals valid for 6 months. Claims will be denied if the member has experienced disease progression on Imjudo or if the drug is used for non-CMS-recognized indications.

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What to do

by Dec 1, 2025 · 7 steps
01Billing team must implement prior authorization requirement for Imjudo (J9313) for all Louisiana Medicaid members.
02Update billing system to require prior auth submission before claims processing for HCC and NSCLC diagnoses.
03Verify member meets criteria: HCC must be unresectable AND combined with Imfinzi; NSCLC must be metastatic/advanced/recurrent WITHOUT EGFR/ALK mutations AND combined with Imfinzi + platinum chemotherapy.
04Screen for exclusion: deny authorization if member has experienced disease progression on Imjudo.
05Configure system to initially approve for 6 months, then require renewal submissions.
06Update provider encounter forms and billing guidance to reference this policy.
07Train front-office and billing staff on new criteria.
If missed: Failure to obtain prior authorization will result in claim denials for Louisiana Medicaid.

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 policiesLA policy changesOncologyHematologyCode J9313

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