Medicare AdvantagePrior AuthMedium impact
Imfinzi (durvalumab) (Revised)
Humana·FL, KY, SC · Oncology, Pulmonology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jul 21, 2026
Summary
Humana revised its Imfinzi (durvalumab) prior authorization policy effective January 1, 2025, covering 10 cancer indications across Medicare and three Medicaid states (Florida, Kentucky, South Carolina). The policy establishes specific clinical criteria, drug combination requirements, and exclusions for each indication. Key exclusion across most indications: disease progression on prior anti-PD-1/PD-L1 therapy disqualifies coverage. All approvals require prior authorization with 6-month initial and renewal periods.
Action Required
By January 1, 2025: Billing team must implement prior authorization workflow for Imfinzi (J7171) across all affected Humana plans and state programs. (1) Update billing software to require prior auth submission before claim submission for all 10 cancer indications listed. (2) Create or update encounter forms/templates to capture: cancer diagnosis type, disease stage/status, planned drug combination regimen, EGFR/ALK/dMMR testing results where applicable, prior anti-PD-1/PD-L1 therapy history, and cycle count for perioperative/adjuvant treatments. (3) Train providers and billing staff on indication-specific criteria (e.g., first-line therapy only for HCC, consolidation therapy only for unresectable NSCLC, maximum 12 cycles for gastric cancer adjuvant). (4) Establish internal tracking for approval duration (6-month increments) and renewal deadlines. (5) Flag any claims where patient has documented disease progression on prior checkpoint inhibitors—these will be automatically denied. Claims submitted without prior authorization or missing required clinical documentation will be denied and require resubmission.