MedicaidPrior AuthMedium impact
Zynyz (retifanlimab-dlwr) (New)
Humana·OH · Oncology·Medicaid
Effective date
Oct 1, 2025
We identified it
Aug 13, 2026
Summary
Humana Medicaid (Ohio) has implemented a new prior authorization policy for Zynyz (retifanlimab-dlwr), a PD-1 inhibitor immunotherapy for Merkel cell carcinoma and squamous cell carcinoma of the anal canal. The policy requires prior authorization for coverage with specific clinical criteria based on cancer type and treatment line. Initial and renewal approvals are limited to 6 months, with a maximum 12-month treatment duration for first-line anal carcinoma therapy.
Action Required
By September 30, 2025: Billing team must configure billing system to require prior authorization for Zynyz (retifanlimab-dlwr) HCPCS code J9312 for all Medicaid (Ohio) claims. Oncology providers must submit prior authorization requests documenting: (1) for Merkel cell carcinoma—diagnosis of recurrent locally advanced or metastatic disease and monotherapy intent, or (2) for anal carcinoma—diagnosis of inoperable locally recurrent or metastatic squamous cell carcinoma with either first-line combination therapy with carboplatin/paclitaxel or single-agent use after platinum-based chemotherapy failure. Verify patient has NO prior anti-PD-1/PD-L1 therapy progression (pembrolizumab, nivolumab). Track approval duration (6 months initial/renewal) and enforce 12-month maximum for first-line anal carcinoma treatment. Update EMR templates with prior auth requirements. Claims submitted without prior authorization will be denied.