Medicare AdvantagePrior AuthMedium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·KY, SC · Ophthalmology·Medicaid
Effective date
Aug 1, 2026
We identified it
Aug 1, 2026
Summary
Humana has established a new prior authorization policy for Cimerli® (ranibizumab-eqrn), a VEGF inhibitor for retinal conditions, effective August 1, 2026. The policy requires step-therapy documentation showing contraindication/intolerance to bevacizumab and failure of prior VEGF inhibitor therapies before approval. This applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid plans.
Action Required
By July 15, 2026: Billing and clinical staff must be trained on the new Cimerli prior authorization requirements for five retinal indications (wet AMD, DME, DR, RVO macular edema, mCNV). Update prior authorization submission templates to require: (1) documented diagnosis matching one of the five approved indications, (2) evidence of bevacizumab contraindication, intolerance, or prior therapy with documented lack of clinical response, and (3) for Medicare requests, documentation of failure with or contraindication to specified comparator agents (varies by indication). Coordinate with ophthalmology/retinal practices and providers to ensure they include required clinical documentation with all Cimerli prior auth requests. Implement system logic to flag Cimerli claims requiring prior authorization before processing. Note: For Medicare Part B continuation therapy within 365 days, step-therapy requirements are waived—ensure billing system can identify and bypass auth for these cases. Failure to obtain prior authorization will result in claim denials.