MedicaidPrior AuthHigh impact
Imfinzi (durvalumab) (New)
Humana·IN · Oncology, Pulmonology, Gastroenterology +1 more·Medicaid
Effective date
Oct 1, 2026
We identified it
Oct 2, 2026
Summary
Humana Medicaid Indiana has released a new pharmacy coverage policy for Imfinzi (durvalumab), effective October 1, 2026. The policy establishes prior authorization requirements for 9 cancer indications with specific clinical criteria and contraindications based on prior anti-PD-1/PD-L1 therapy exposure. Billing teams must implement prior authorization workflows for all Imfinzi claims and verify member eligibility against documented diagnosis, treatment regimen, and exclusion criteria.
Action Required
By October 1, 2026: Billing team must implement prior authorization requirement for HCPCS code J9173 (Imfinzi/durvalumab injection) for all Medicaid Indiana members. Update billing system to require prior auth submission before claim submission. For each claim, verify: (1) member has documented diagnosis matching one of 9 covered indications (biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, NSCLC-metastatic, NSCLC-perioperative, NSCLC-unresectable, small cell lung cancer extensive-stage, or small cell lung cancer limited-stage); (2) treatment regimen matches policy-specified drug combinations for each indication; (3) member has no prior disease progression on anti-PD-1/PD-L1 agents (nivolumab, pembrolizumab, atezolizumab, or prior durvalumab); (4) dose/cycle limits are not exceeded (12 cycles max for GE/GEJC and perioperative NSCLC; 12 months max for unresectable NSCLC). Providers must submit documentation supporting medical necessity including pathology reports, staging documentation, prior treatment history, and confirmation of specific drug combinations. Initial authorization is 6 months; renewals require recertification. Claims submitted without prior authorization will be denied. Update encounter templates and prior auth submission forms to require providers document the specific indication and treatment regimen. Train billing staff on the 9 distinct clinical pathways and their specific approval criteria.