Medicare AdvantagePrior AuthMedium impact
Bavencio® (avelumab) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 22, 2026
Summary
Humana revised its Bavencio (avelumab) prior authorization policy effective July 22, 2026, affecting coverage for renal cell carcinoma, Merkel cell carcinoma (adults and pediatrics age 12+), and urothelial cancer across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains prior authorization requirements with specific clinical criteria and exclusions for each indication. Billing teams must verify member eligibility against the updated criteria and ensure prior authorization is obtained before claims submission.
Action Required
By July 22, 2026: Billing team must review and implement the revised Bavencio prior authorization policy. Update billing system workflows to ensure prior authorization is required for all Bavencio (avelumab) claims. Verify each claim meets the specific clinical criteria for the applicable indication: (1) for renal cell carcinoma—member must have advanced/metastatic disease AND be receiving combination therapy with Inlyta as first-line; (2) for Merkel cell carcinoma (adults)—member must have metastatic disease AND be receiving monotherapy; (3) for Merkel cell carcinoma (pediatrics)—member must be age 12+ with metastatic disease AND receiving monotherapy; (4) for urothelial cancer—member must have locally advanced/metastatic disease AND be receiving monotherapy as second+ line, or following disease progression within 12 months of neoadjuvant/adjuvant chemotherapy, or as maintenance treatment. Confirm members do NOT have disease progression on/after PD-1/PD-L1 therapy (Keytruda, Opdivo, Tecentriq, Imfinzi), which is an exclusion criterion. For Florida, Kentucky, and South Carolina Medicaid members, cross-check state-specific requirements. Document all clinical criteria in claim submission. Claims submitted without prior authorization or missing required clinical documentation will be denied. Providers should be notified of the updated requirements to facilitate timely prior authorization requests.