MedicaidPrior AuthHigh impact
Imfinzi (durvalumab) (New)
Humana·LA · Oncology·Medicaid
Effective date
Oct 1, 2026
We identified it
Oct 2, 2026
Summary
Humana Medicaid (Louisiana) has implemented a new prior authorization policy for Imfinzi (durvalumab) effective October 1, 2026, covering 10 oncologic indications including biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy requires specific combination chemotherapy regimens and excludes patients with prior disease progression on anti-PD-1/PD-L1 therapies.
Action Required
By September 15, 2026: Billing team must update the prior authorization system to require approval for all Imfinzi (durvalumab/J9173) claims for Louisiana Medicaid members. For each indication covered, verify the following BEFORE submitting claims: (1) Diagnosis confirmation (biliary tract, endometrial, gastric/GE junction, hepatocellular carcinoma, NSCLC metastatic/perioperative/unresectable, small cell lung cancer extensive/limited stage, or bladder cancer); (2) Combination therapy specifications are met (gemcitabine+cisplatin for biliary; carboplatin+paclitaxel followed by monotherapy for endometrial dMMR; FLOT regimen for gastric; Imjudo+tremelimumab for hepatocellular and metastatic NSCLC; appropriate chemo for other indications); (3) No disease progression history on prior anti-PD-1/PD-L1 therapy (Opdivo, Keytruda, Tecentriq, or prior Imfinzi). Create prior auth submission templates by indication. Update encounter forms to include mandatory documentation fields for diagnosis stage, tumor characteristics (EGFR/ALK status for lung cancer, dMMR status for endometrial), prior cancer therapy history, and planned combination regimen. Educate oncology providers on cycle limits: max 12 cycles for gastric/GE junction and perioperative NSCLC adjuvant treatment; max 12 months for unresectable NSCLC. Claims submitted without required prior authorization or missing medical necessity documentation will be denied.