MedicaidPrior AuthHigh impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·OH · Ophthalmology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 1, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), an intravitreal VEGF inhibitor for five retinal conditions. Coverage requires either a documented contraindication/intolerance to bevacizumab OR failure of prior bevacizumab therapy with provider attestation of lack of clinical response. This is a step-therapy requirement effective August 1, 2026.
Action Required
By August 1, 2026: Billing team must implement prior authorization requirements for all Cimerli® (ranibizumab-eqrn) claims submitted to Humana Medicaid Ohio. Update billing system to flag requests and require providers to submit: (1) diagnosis confirmation for wet AMD, DME, DR, RVO, or mCNV; (2) evidence of bevacizumab contraindication/intolerance OR documentation that prior bevacizumab therapy failed to demonstrate clinical response (BCVA improvement/maintenance, visual field stability, or reduced vision decline rate). Providers must include clinical attestation in prior authorization requests. Front desk staff should educate referring ophthalmologists about the step-therapy requirement before submitting claims. Claims submitted without proper prior authorization documentation will be denied. Reference www.humana.com/PAL for applicable medical and procedural coding information.