All Insurance Policy Changes (Page 128)

Continuing from page 127. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Austedo® & Austedo® XR (deutetrabenazine) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for Austedo and Austedo XR (deutetrabenazine) effective January 1, 2022, with the most recent revision dated June 24, 2026. The policy establishes clear prior authorization requirements for two indications: tardive dyskinesia (with specific criteria regarding dopamine receptor-blocking agent use or discontinuation) and chorea associated with Huntington's disease. Approval duration is plan year for both initial and renewal requests, with important contraindications, dose adjustments, and black box warnings documented.
Medium impact
Enjaymo™ (sutimlimab-jome) (Revised)
Humana·Effective Jul 27, 2022
This is a revised Medicaid (Ohio) prior authorization policy for Enjaymo (sutimlimab-jome), a complement inhibitor for cold agglutinin disease. The policy establishes strict initial authorization criteria including diagnosis confirmation, hemoglobin thresholds, vaccination requirements, and rituximab interaction restrictions, plus renewal criteria based on demonstrated efficacy. Billing teams must implement prior authorization requirements before claims submission.
Medium impact
Ferriprox® (deferiprone) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage updated its Ferriprox (deferiprone) prior authorization policy effective January 1, 2024 (revised June 24, 2026). Coverage requires diagnosis of transfusional iron overload secondary to thalassemia syndromes with documented failure, contraindication, or intolerance to deferasirox, plus serum ferritin >2,500 mcg/L. Patients must demonstrate ≥20% decline in serum ferritin after therapy initiation or coverage may be denied. Billing teams must implement prior authorization requirements before dispensing either tablet or oral solution formulations.
Medium impact
Enjaymo™ sutimlimab-jome (Revised)
Humana·Effective Jul 23, 2025
Humana revised its prior authorization policy for Enjaymo (sutimlimab-jome) for Cold Agglutinin Disease treatment effective July 23, 2025. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires strict prior authorization criteria including diagnosis confirmation, hemoglobin/bilirubin lab values, bacterial vaccination requirements, and restrictions on concomitant rituximab/chemotherapy use. Continuation therapy requires documented efficacy (hemoglobin increase of 2g/dL or more, normalization to ≥12g/dL, or decreased transfusion need).
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Gamifant (emapalumab-lzsg) prior authorization policy for Ohio Medicaid effective November 1, 2025, with a revision date of June 24, 2026. The policy establishes coverage criteria for two distinct indications: primary HLH requiring documented gene mutation or 5+ clinical characteristics plus failed conventional therapy and stem cell transplant candidacy, and HLH/MAS in Still's disease requiring inadequate response to glucocorticoids or recurrent MAS. All approvals require concurrent dexamethasone administration and carry 6-month initial and renewal periods.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Humana Medicaid (Indiana) prior authorization policy for Gamifant® (emapalumab-lzsg), an intravenous monoclonal antibody for treating primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. The policy establishes strict criteria requiring documented genetic mutations or clinical HLH-2004 diagnostic criteria, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy for approval. Initial and renewal approvals are limited to 6-month periods.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Gamifant® (emapalumab-lzsg) effective November 1, 2025, with revisions dated June 24, 2026. The policy establishes specific criteria for coverage of this IFN-gamma neutralizing antibody for primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. All Gamifant prescriptions require prior authorization with documented evidence of HLH diagnosis, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy.
Medium impact
Leqvio® (inclisiran) (Revised)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has revised its prior authorization policy for Leqvio® (inclisiran) effective July 1, 2026. The policy clarifies coverage criteria for hypercholesterolemia and heterozygous familial hypercholesterolemia (HeFH) patients aged 18+, requiring adjunctive therapy to maximally tolerated statins or documentation of statin-associated muscle symptoms (SAMs). A separate pathway covers pediatric homozygous familial hypercholesterolemia (HoFH) patients aged 12+. All Leqvio prescriptions now require prior authorization before dispensing.
Medium impact
Kineret (anakinra) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Kineret (anakinra) prior authorization policy effective January 1, 2026, with updates as of June 24, 2026. For rheumatoid arthritis patients, the policy now requires prior authorization with specific criteria: diagnosis of moderately to severely active RA, age 18+, and documented previous treatment failure or intolerance to at least two of three preferred agents (adalimumab products, Enbrel, or Rinvoq). The policy maintains coverage for CAPS (NOMID) and DIRA indications with separate authorization criteria.
Medium impact
Kevzara (sarilumab) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Kevzara (sarilumab) effective January 1, 2026, with updates as of June 24, 2026. The policy establishes specific clinical criteria for coverage across three indications: moderate to severe rheumatoid arthritis (requires 2 prior therapy failures/contraindications), polymyalgia rheumatica (requires 1 prior corticosteroid therapy/contraindication), and polyarticular juvenile idiopathic arthritis in patients ≥63 kg (requires 2 prior therapy failures/contraindications). All Kevzara requests require prior authorization before dispensing.
Medium impact
Fosaprepitant products (Emend, Focinvez) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for fosaprepitant products (Emend, Focinvez) effective January 1, 2026, with a revision date of June 24, 2026. Coverage requires the medication be used for prophylaxis (not treatment) of chemotherapy-induced nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy, AND must be part of a regimen that includes both a corticosteroid and a 5-HT3 antagonist, or the patient must have a contraindication to one of these drug classes. Prior authorization is required before dispensing.
Medium impact
Deferasirox Products (Revised)
Humana·Effective Jan 1, 2026
Humana has updated its Deferasirox Products prior authorization policy effective January 1, 2026, with a revision date of June 24, 2026. This policy establishes mandatory prior authorization requirements for all deferasirox products (Jadenu, Exjade, and generic formulations) for Medicare Advantage members with chronic iron overload. The policy defines specific clinical criteria for two indications: transfusional iron overload (ferritin >1000 mcg/L initially, >500 mcg/L for renewal) and non-transfusion dependent thalassemia syndromes (liver iron concentration ≥5 mg/gm initially, ≥3 mg/gm for renewal), with absolute contraindications including platelet counts <50,000/microliter and eGFR <40 mL/min/1.73m².
Medium impact
Bimzelx (bimekizumab-bkzx) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for Bimzelx (bimekizumab-bkzx), effective January 1, 2026, with a June 24, 2026 revision. The policy establishes specific prior authorization criteria for five approved indications: plaque psoriasis, psoriatic arthritis, non-radiographic axial spondyloarthritis, ankylosing spondylitis, and hidradenitis suppurativa. All requests require prior auth, with varying pre-treatment requirements (typically 2 prior failed therapies) depending on the diagnosis.
Medium impact
Akynzeo (fosnetupitant-palonosetron/netupitant- palonosetron) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage revised its Akynzeo (fosnetupitant-palonosetron/netupitant-palonosetron) prior authorization policy effective January 1, 2026, with updates as of June 24, 2026. For oral capsules, prior authorization now requires documented failure, contraindication, or significant side effects with aprepitant before Akynzeo approval. Both oral and IV formulations require use with highly emetogenic or moderately emetogenic chemotherapy. This is a revised policy that supersedes any previous Akynzeo guidance.
Medium impact
Hyrnuo (sevabertinib)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage now requires prior authorization for Hyrnuo (sevabertinib) when treating locally advanced or metastatic non-squamous NSCLC with HER2 TKD activating mutations in patients who have received prior systemic therapy. The medication must be prescribed as monotherapy to qualify for coverage. This is a new pharmacy policy effective February 25, 2026.
Medium impact
Exdensur™ (depemokimab-ulaa) (Revised)
Humana·Effective Jul 1, 2026
Humana revised its prior authorization policy for Exdensur™ (depemokimab-ulaa) effective July 1, 2026, covering Medicare Part D, Medicare Part B, and Medicaid (Kentucky and South Carolina). For Medicaid requests, the policy requires members to have severe asthma with eosinophilic phenotype (≥150 cells/μL at initiation or ≥300 cells/μL in prior 12 months) and failed adequate control on maximum tolerated inhaled corticosteroid plus long-acting beta agonist therapy. Prior authorization is mandatory before dispensing.
Low impact
LAMZEDE® (velmanase alfa-tycv) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Ohio has established a new prior authorization policy for LAMZEDE® (velmanase alfa-tycv) effective July 1, 2026. This enzyme replacement therapy for non-central nervous system manifestations of alpha-mannosidosis now requires prior authorization. Billing teams must implement prior auth requirements for intravenous LAMZEDE administration to avoid claim denials.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid-Indiana has established a new Prior Authorization policy for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager for treating extensive-stage small cell lung cancer (ES-SCLC) with disease progression after platinum-based chemotherapy. All Imdelltra claims require prior authorization effective July 1, 2026, and approval is contingent on meeting specific clinical criteria and avoiding exclusions related to disease progression while on therapy.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Louisiana Medicaid has implemented a new prior authorization policy for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager for extensive-stage small cell lung cancer. Coverage requires patients to have ES-SCLC with disease progression after platinum-based chemotherapy, with denial of approval if disease progression occurs while on Imdelltra. Prior authorization is mandatory before dispensing.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization requirement for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager indicated for extensive-stage small cell lung cancer with disease progression after platinum-based chemotherapy. Coverage requires prior auth approval for initial and renewal periods, with specific clinical criteria and exclusions based on treatment history and disease response.
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Identified Jul 1, 2026
Failed to analyze policy change
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Indiana) has established a new prior authorization policy for Exdensur™ (depemokimab-ulaa), an IL-5 antagonist for severe asthma with eosinophilic phenotype. Billing teams must implement prior authorization requirements before July 1, 2026, and ensure all three clinical criteria are documented before claim submission.
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Effective Jul 1, 2026
Humana Louisiana Medicaid is implementing a new prior authorization policy for Exdensur™ (depemokimab-ulaa), a biologic treatment for severe eosinophilic asthma. This is a NEW policy effective July 1, 2026, requiring prior authorization before dispensing. Billing teams must verify three clinical criteria (severe asthma diagnosis, elevated eosinophil levels ≥150 cells/μL or ≥300 cells/μL in past 12 months, and inadequate control on maximum inhaled corticosteroids with LABA) are met before submitting claims.
Medium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Identified Jul 1, 2026
Humana Medicare Advantage has implemented a new Prior Authorization policy for Cimerli® (ranibizumab-eqrn), a ranibizumab biosimilar used for retinal conditions. Billing teams must obtain prior authorization before administering this drug to Medicare Advantage members to avoid claim denials.
Medium impact
Adcetris® (brentuximab vedotin) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Indiana has implemented a new prior authorization policy for Adcetris (brentuximab vedotin) effective July 1, 2026. This policy requires prior auth approval for seven distinct lymphoma indications with specific clinical criteria, approval durations of 6 months initially and at renewal, and explicit exclusions for patients experiencing disease progression on the drug.

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Archive by year

2023 2024 2025 2026

Austedo® & Austedo® XR (deutetrabenazine) (Revised)

Enjaymo™ (sutimlimab-jome) (Revised)

Ferriprox® (deferiprone) (Revised)

Enjaymo™ sutimlimab-jome (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Leqvio® (inclisiran) (Revised)

Kineret (anakinra) (Revised)

Kevzara (sarilumab) (Revised)

Fosaprepitant products (Emend, Focinvez) (Revised)

Deferasirox Products (Revised)

Bimzelx (bimekizumab-bkzx) (Revised)

Akynzeo (fosnetupitant-palonosetron/netupitant- palonosetron) (Revised)

Hyrnuo (sevabertinib)

Exdensur™ (depemokimab-ulaa) (Revised)

LAMZEDE® (velmanase alfa-tycv) (New)

Imdelltra (tarlatamab-dlle) (New)

Imdelltra (tarlatamab-dlle) (New)

Imdelltra (tarlatamab-dlle) (New)

Exdensur™ (depemokimab-ulaa) (New)

Exdensur™ (depemokimab-ulaa) (New)

Exdensur™ (depemokimab-ulaa) (New)

Cimerli® (ranibizumab-eqrn) (New)

Adcetris® (brentuximab vedotin) (New)