MedicaidPrior AuthMedium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·IN · Ophthalmology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 1, 2026
Summary
Humana Medicaid Indiana has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), a VEGF inhibitor for retinal conditions. Coverage requires documented diagnosis of one of five qualifying eye conditions AND either contraindication/intolerance to bevacizumab OR documented failure to achieve positive clinical response with prior bevacizumab therapy. All claims for this drug require prior authorization before dispensing.
Action Required
By August 1, 2026: (1) Billing team must implement prior authorization requirement for all Cimerli (ranibizumab-eqrn) claims submitted to Humana Medicaid Indiana. (2) Update billing system to flag claims and prevent submission without prior auth documentation. (3) Providers must include in prior auth requests: confirmed diagnosis (AMD, DME, DR, RVO, or mCNV); documentation of bevacizumab contraindication/intolerance OR evidence that member did NOT respond positively to prior bevacizumab (specific metrics: BCVA improvement/maintenance, visual field changes, or reduction in vision decline rate). (4) Front desk/clinical staff should verify member's Humana Medicaid Indiana eligibility before referrals. (5) Ensure pharmacy team understands step-therapy requirement does not apply to continuations within past 365 days (for Medicare Part B only, if applicable). Claims submitted without completed prior authorization will be denied.