MedicaidPrior AuthHigh impact
Imfinzi (durvalumab)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Oct 1, 2026
We identified it
Oct 15, 2026
Summary
Humana Indiana Medicaid has established a prior authorization policy for Imfinzi (durvalumab) covering nine cancer indications including biliary tract cancer, endometrial cancer, gastric/gastroesophageal junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, and unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy specifies coverage criteria, treatment combinations, exclusions (including prior anti-PD-1/PD-L1 therapy), and approval durations of 6 months per initial or renewal authorization.
Action Required
REQUIREMENTS: Effective immediately (2026-10-01): Billing team must implement prior authorization requirements for all Imfinzi (durvalumab) claims for Indiana Medicaid members across all nine covered cancer indications. Specifically: (1) Update billing system and prior authorization software to require PA requests for HCPCS code J9173 when billed to Humana Indiana Medicaid; (2) Ensure clinical teams verify member meets all indication-specific criteria before treatment initiation (e.g., for biliary tract cancer: locally advanced/metastatic disease AND combination use with gemcitabine and cisplatin); (3) Screen for exclusions at time of PA request, particularly disease progression on/following anti-PD-1/PD-L1 agents (Opdivo, Keytruda, Tecentriq, prior Imfinzi); (4) Configure system to issue initial authorizations for 6 months maximum or as determined through clinical review, with 6-month renewal cycles; (5) Communicate updated requirements to all ordering providers and clinical staff. Without prior authorization submission, claims will be denied. Reference the full policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5f54c0 to verify current applicability before processing each claim.