MedicaidPrior AuthHigh impact
Imfinzi (durvalumab) (New)
Humana·OH · Oncology, Pulmonology, Hematology +1 more·Medicaid
Effective date
Oct 1, 2026
We identified it
Oct 2, 2026
Summary
Humana Medicaid Ohio has issued a new prior authorization policy for Imfinzi (durvalumab) covering 10 cancer indications, effective October 1, 2026. The policy requires prior authorization for all covered uses and establishes specific clinical criteria, drug combination requirements, and exclusions (including prior anti-PD-1/PD-L1 therapy failure) for each indication. Billing teams must implement prior authorization workflows immediately upon the effective date.
Action Required
By October 1, 2026: (1) Billing team must implement prior authorization requirement for Imfinzi (J9173) in billing system for all covered indications: biliary tract cancer, endometrial cancer, gastric/gastroesophageal junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, unresectable), small cell lung cancer (extensive-stage and limited-stage), and bladder cancer. (2) Update encounter forms and EMR templates to prompt providers to document: cancer diagnosis, disease stage/resectability status, specific drug combination being used, prior immunotherapy history, and treatment intent (neoadjuvant, adjuvant, consolidation, maintenance). (3) Create pre-claim submission checklist requiring: verification of disease stage/genomic status (EGFR/ALK for NSCLC), documentation that patient has NOT progressed on prior anti-PD-1/PD-L1 therapy, confirmation of appropriate drug combinations per indication, and cycle/duration limits (max 12 cycles for perioperative NSCLC and gastric cancer, max 12 months for unresectable NSCLC). (4) Configure billing software to deny claims lacking prior authorization approval. (5) Train billing staff on indication-specific criteria and exclusion triggers. (6) Providers must obtain prior authorization before dispensing or administering Imfinzi; claims will be denied without valid prior auth approval.