MedicaidPrior AuthMedium impact
Imfinzi (durvalumab)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Oct 1, 2026
We identified it
Oct 15, 2026
Summary
Humana Medicaid in Ohio updated its prior authorization policy for Imfinzi (durvalumab) effective October 1, 2026, establishing coverage criteria and exclusions across nine cancer indications including biliary tract, endometrial, gastric, hepatocellular, lung, and bladder cancers. The policy specifies required combination therapies, disease staging requirements, and treatment duration limits for each indication, with standard 6-month initial and renewal approval periods subject to clinical review.
Action Required
Effective 2026-10-01: Billing team must implement prior authorization requirements in the billing system for Imfinzi (durvalumab, HCPCS J9173) for Ohio Medicaid members. Before submitting claims, verify that the member's cancer diagnosis and treatment regimen match one of the nine covered indications (biliary tract, endometrial, gastric, hepatocellular, metastatic NSCLC, perioperative NSCLC, unresectable stage III NSCLC, extensive-stage small cell lung cancer, or limited-stage small cell lung cancer) and that exclusion criteria are not met—particularly prior disease progression on anti-PD-1/PD-L1 therapies. Update intake forms and prior authorization submission templates to capture required clinical information: specific cancer stage/type, concurrent chemotherapy agents, treatment phase (neoadjuvant, adjuvant, consolidation, or first-line), and prior immunotherapy history. Confirm current applicability of this policy before implementation by referencing Humana's online policy portal, as printed copies become uncontrolled. Claims submitted without proper prior authorization or that do not meet the stated criteria will be subject to denial.