MedicaidPrior AuthMedium impact
Papzimeos™ (zopapogene imadenovec-drba) (Revised)
Humana·IN · ENT (Ear, Nose & Throat), Pulmonology, Infectious Disease·Medicaid
Effective date
Dec 1, 2025
We identified it
Jul 21, 2026
Summary
Humana Indiana Medicaid implemented a revised prior authorization policy for Papzimeos (zopapogene imadenovec-drba), an immunotherapy for recurrent respiratory papillomatosis (RRP). The policy requires prior authorization for this drug and mandates that members meet four specific criteria: biopsy-confirmed RRP diagnosis, concurrent surgical debulking/removal procedures, age 18+, and supporting clinical documentation. Members who have previously completed a treatment course are excluded from coverage.
Action Required
By December 1, 2025: Billing and prior authorization teams must implement the following: (1) Establish prior authorization requirement for all Papzimeos claims submitted under Medicaid Indiana; (2) Update billing system and pre-authorization workflows to require submission of biopsy-confirmed RRP diagnosis documentation before claim processing; (3) Verify member age is 18 or older at time of authorization request; (4) Confirm that surgical debulking/removal procedures are scheduled or documented as occurring concurrently with Papzimeos administration (initial debulking before first dose, and additional procedures before 3rd and 4th doses); (5) Reject or request additional documentation for any members with evidence of previous Papzimeos treatment course completion; (6) Train providers and billing staff that prior authorization denials will be issued for missing documentation, non-compliance with surgical debulking requirements, or prior treatment completion history. Provider credentialing and care coordination teams should communicate these requirements to ENT and pulmonology practices that may manage RRP patients.