All Insurance Policy Changes (Page 151)

Continuing from page 150. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Multi-Source Brands (Revised)
Humana·Effective Aug 24, 2007
Humana revised its Multi-Source Brands pharmacy coverage policy (effective August 24, 2007, with revision date December 17, 2025) to clarify utilization management requirements for brand-name drugs that have lost patent protection. Multi-Source Brand products now require prior authorization review, and coverage is medically necessary only when members have had previous treatment failure, intolerance, or contraindication to an AB-rated generic equivalent. This policy applies to all commercially available strengths and dosage forms, including drugs in the six protected Medicare classes (immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics).
Medium impact
Arcalyst® (rilonacept) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Arcalyst (rilonacept) prior authorization policy effective December 17, 2025, clarifying coverage criteria for three distinct indications: Cryopyrin-Associated Periodic Syndrome (CAPS) including FCAS/MWS (age 12+), recurrent pericarditis (age 12+), and DIRA (no age restriction). The policy maintains prior authorization requirements with plan year approval durations and reinforces contraindications for active/chronic infections and concurrent live vaccines.
Low impact
Elaprase® (idursulfase) (Revised)
Humana·Effective Aug 27, 2025
This is a routine revision of Humana's Elaprase (idursulfase) prior authorization policy for Hunter Syndrome treatment, effective for Medicare, Kentucky Medicaid, and South Carolina Medicaid. The policy maintains the existing single approval criterion (confirmed Hunter Syndrome diagnosis) and approval duration structure (plan year or clinical review). No substantive coverage changes are indicated; this appears to be a standard policy maintenance update.
Medium impact
Uloric® (febuxostat) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage updated its Uloric (febuxostat) step therapy policy effective January 28, 2026. The policy reinforces that febuxostat requires prior step therapy—patients must have documented previous treatment failure, intolerance, or contraindication to allopurinol before approval. The policy emphasizes the 2019 FDA black box warning regarding cardiovascular death risk in gout patients with established cardiac disease, requiring careful risk-benefit assessment by providers.
Medium impact
Ilaris® (canakinumab) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Ilaris (canakinumab) prior authorization policy for Medicare Advantage members effective November 26, 2025. The policy maintains coverage criteria across six indications (CAPS/FCAS/MWS, Still's Disease, TRAPS, FMF, HIDS/MKD, and gout flare) with specific age and clinical thresholds for each condition. The revision date of November 26, 2025 indicates this is a routine policy refresh; however, billing teams must verify all prior authorization requirements are being enforced in claims processing systems.
Medium impact
Ozurdex® (dexamethasone intravitreal implant) (Revised)
Humana·Effective Nov 26, 2025
This is a routine policy revision for Ozurdex (dexamethasone intravitreal implant) covering three indications: macular edema from retinal vein occlusion, non-infectious posterior segment uveitis, and diabetic macular edema. The policy requires prior authorization for all three indications across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina) with consistent exclusion criteria (advanced glaucoma, aphakic eyes with posterior lens capsule rupture, ACIOL with posterior lens capsule rupture).
Medium impact
Folotyn® (pralatrexate) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Folotyn (pralatrexate) prior authorization policy effective November 26, 2025, for Medicare, Medicaid-Florida, and Medicaid-South Carolina. The policy maintains prior authorization requirements for relapsed or refractory peripheral T-cell lymphoma (PTCL) treatment and reinforces the exclusion criterion that members experiencing disease progression while on Folotyn may not be approved for continued coverage.
Medium impact
Provenge® (sipuleucel-T) (Revised)
Humana·Effective Dec 17, 2025
This is a revised Provenge® (sipuleucel-T) prior authorization policy effective December 17, 2025, for Medicaid programs in Florida, Kentucky, and South Carolina, plus Medicare. The policy maintains coverage for asymptomatic or minimally symptomatic metastatic castrate-resistant prostate cancer with strict eligibility criteria (ECOG 0-1, no visceral disease) and explicitly excludes concomitant use with Zytiga or Xtandi due to insufficient safety/efficacy evidence.
Medium impact
Drug Utilization Management and Clinical Edits Tools (Revised)
Humana·Effective Aug 28, 2010
This is a guidance policy update (revised November 26, 2025) that clarifies Humana's Drug Utilization Management and Clinical Edits Tools across Medicare and multiple state Medicaid programs. The policy outlines how Humana applies prospective clinical edits (prior authorization, quantity limits, step therapy, duplication edits, drug/drug interactions, accumulation edits, and age/gender/disease/pregnancy edits) to ensure safe and cost-effective medication therapy. The policy specifies grandfathering exceptions for four drug classes (antidepressants, antipsychotics, anticonvulsants for epilepsy, antineoplastics, antiretrovirals, and immunosuppressants) and clarifies that drug samples do not count as treatment experience for prior authorization or step therapy requirements.
Low impact
Carbaglu® (carglumic acid) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage has revised its prior authorization policy for Carbaglu (carglumic acid) effective November 26, 2025. The policy covers this rare disease medication for three indications: acute or chronic hyperammonemia due to NAGS deficiency, and acute hyperammonemia due to propionic acidemia (PA) or methylmalonic acidemia (MMA). Prior authorization is required for all covered uses, with approval granted for the plan year duration initially and renewable annually.
Medium impact
Egrifta® (tesamorelin acetate) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Egrifta® (tesamorelin acetate) prior authorization policy for Medicare Advantage members with HIV-associated lipodystrophy on September 24, 2025. The policy maintains three approval criteria: diagnosed HIV-associated lipodystrophy, use for abdominal fat reduction, and current or prior protease inhibitor/nucleoside reverse transcriptase inhibitor therapy. No changes to coverage criteria are evident, but this revision should be verified against the previous version to identify specific modifications.
Low impact
Lumizyme® (alglucosidase alpha) (Revised)
Humana·Effective Jan 1, 2011
This is a routine policy revision for Lumizyme (alglucosidase alpha) coverage under Humana's Medicaid plans in Kentucky and South Carolina, effective January 1, 2011, with the most recent update dated August 27, 2025. The policy maintains prior authorization requirements for this orphan drug used to treat Pompe disease, with approvals granted for plan year durations or through clinical review. No substantive coverage changes are documented in this revision; this appears to be a standard periodic policy refresh with updated prescribing information references.
Medium impact
Adcetris® (brentuximab vedotin) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Adcetris® (brentuximab vedotin) prior authorization policy effective April 22, 2026, clarifying coverage criteria across seven lymphoma indications for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains six-month initial and renewal approval durations with disease progression as a common exclusion criterion across all indications.
Low impact
Fabrazyme® (agalsidase beta) and Elfabrio® (pegunigalsidase alfa) (Revised)
Humana·Effective Jan 1, 2012
Humana revised its prior authorization policy for Fabrazyme (agalsidase beta) and Elfabrio (pegunigalsidase alfa) on December 17, 2025, affecting Medicare and Medicaid (Kentucky and South Carolina) members. The policy maintains the single approval criterion: documented diagnosis of Fabry disease. No significant coverage changes were identified; this appears to be a routine policy refresh with updated effective dates.
Medium impact
Elitek® (rasburicase) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Elitek® (rasburicase) prior authorization policy effective March 25, 2026 for Medicare and Medicaid (Florida and Kentucky). The policy requires prior authorization for rasburicase use in cancer patients at risk for tumor lysis syndrome, with two mandatory approval criteria (malignancy diagnosis + chemotherapy expected to cause TLS) and two critical exclusions (G6PD deficiency and prior hemolytic reactions/methemoglobinemia). No changes to billing codes or reimbursement were identified; this is a clarification/reaffirmation of existing prior auth requirements.
Medium impact
Erivedge® (vismodegib) (Revised)
Humana·Effective Apr 22, 2026
Humana updated its Erivedge (vismodegib) prior authorization policy for Medicare Advantage members with basal cell carcinoma. The policy clarifies eligibility criteria requiring metastatic or locally advanced BCC (with recurrence or ineligibility for surgery/radiation), excludes members with disease progression on Erivedge or using it as neoadjuvant therapy, and maintains six-month approval durations for initial and renewal authorizations.
Low impact
Korlym® (mifepristone) (Revised)
Humana·Effective Dec 17, 2025
Humana Medicare Advantage revised its Korlym® (mifepristone) pharmacy coverage policy effective December 17, 2025. The policy maintains prior authorization requirements for this medication, which is indicated to control hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing's syndrome who have type 2 diabetes or glucose intolerance and have failed surgery or are not surgical candidates. No substantial coverage criteria changes are evident, but the revision date indicates policy clarification or administrative updates have been made.
Medium impact
Neupro® (rotigotine) (Revised)
Humana·Effective Jan 24, 2024
This is a revised Humana Commercial prior authorization policy for Neupro® (rotigotine) transdermal patches, effective January 24, 2024. The policy maintains prior authorization requirements for two indications: Parkinson's Disease (requires diagnosis plus prior treatment/contraindication/intolerance to ropinirole and pramipexole OR diagnosis of dysphagia) and Restless Legs Syndrome (requires moderate-to-severe primary RLS diagnosis plus prior treatment/contraindication/intolerance to ropinirole and pramipexole). Approval duration is for the initial plan year.
Low impact
Elelyso® (taliglucerase alfa) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Elelyso® (taliglucerase alfa) prior authorization policy effective March 25, 2026. The policy maintains coverage for Type 1 Gaucher disease treatment in Medicare and Medicaid (Kentucky and South Carolina) members, requiring confirmed diagnosis as the primary approval criterion. This is a routine policy revision with no substantive coverage changes from the previous version.
High impact
Medication Waste (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Medication Waste guidance policy (effective 12/17/2025) clarifying when single-dose vial waste can be billed with the JW modifier. Key requirement: medication administered and wasted must be billed on the same claim with detailed documentation (date, time, amount, reason), and waste cannot be billed for multi-dose vials. Any discrepancies between billed and documented amounts will result in denials unless wastage is clearly documented.
Medium impact
Member Cost-Share Waiver: Contraceptives (Revised)
Humana·Effective Nov 29, 2023
Humana revised its Member Cost-Share Waiver policy for contraceptives, effective November 29, 2023. The policy clarifies that preferred contraceptives are covered with zero cost-share at network pharmacies, while non-preferred contraceptives require a cost-share waiver only when the member has tried at least two preferred alternatives or has documented medical necessity. This is a pharmacy coverage guidance policy under the Affordable Care Act requiring no cost-sharing for FDA-approved contraceptive methods.
Medium impact
Naglazyme® (galsulfase) (Revised)
Humana·Effective Jan 1, 2013
This is a revised Naglazyme (galsulfase) prior authorization policy for Medicare and Medicaid (Kentucky and South Carolina) effective January 1, 2013, with the most recent revision dated March 25, 2026. The policy requires prior authorization for Naglazyme intravenous solution and establishes that the single approval criterion is a confirmed diagnosis of mucopolysaccharidosis VI (MPS VI; Maroteaux-Lamy syndrome). The policy includes detailed warnings about anaphylaxis, allergic reactions, immune-related reactions, cardiorespiratory risk, and infusion reactions requiring appropriate monitoring and pretreatment protocols.
Medium impact
Cytogam® (cytomegalovirus immune globulin, human) (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage revised its Cytogam (cytomegalovirus immune globulin) prior authorization policy effective March 25, 2026. The policy maintains coverage for CMV prophylaxis in five organ transplant types (heart, liver, pancreas, kidney, lung) with consistent prior auth requirements: member must be CMV seronegative AND organ donor must be CMV seropositive. Members with selective IgA deficiency are excluded. Approval duration remains 6 months initial and 6 months for renewal.
Medium impact
Aldurazyme® (laronidase) (Revised)
Humana·Effective Jan 1, 2013
Humana revised its Aldurazyme (laronidase) prior authorization policy effective January 1, 2013, with a revision date of May 27, 2026. The policy covers this enzyme replacement therapy for Mucopolysaccharidosis 1 (MPS 1) across Medicare and Medicaid (Kentucky and South Carolina) plans. Prior authorization is required for all Aldurazyme claims, and coverage is limited to patients with Hurler or Hurler-Scheie forms of MPS 1, or Scheie form with moderate to severe symptoms.
Low impact
Ravicti® (glycerol phenylbutyrate) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage updated its Ravicti® (glycerol phenylbutyrate) prior authorization policy on November 26, 2025. The policy maintains existing coverage criteria requiring diagnosis of urea cycle disorders, concurrent use with low-protein diet, and prior trial/contraindication of sodium phenylbutyrate products. A critical exclusion remains: Ravicti is not covered for N-acetylglutamate synthetase (NAGS) deficiency treatment. No changes to approval duration or billing codes were made in this revision.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 151) | PolicyChanges.app

Multi-Source Brands (Revised)

Arcalyst® (rilonacept) (Revised)

Elaprase® (idursulfase) (Revised)

Uloric® (febuxostat) (Revised)

Ilaris® (canakinumab) (Revised)

Ozurdex® (dexamethasone intravitreal implant) (Revised)

Folotyn® (pralatrexate) (Revised)

Provenge® (sipuleucel-T) (Revised)

Drug Utilization Management and Clinical Edits Tools (Revised)

Carbaglu® (carglumic acid) (Revised)

Egrifta® (tesamorelin acetate) (Revised)

Lumizyme® (alglucosidase alpha) (Revised)

Adcetris® (brentuximab vedotin) (Revised)

Fabrazyme® (agalsidase beta) and Elfabrio® (pegunigalsidase alfa) (Revised)

Elitek® (rasburicase) (Revised)

Erivedge® (vismodegib) (Revised)

Korlym® (mifepristone) (Revised)

Neupro® (rotigotine) (Revised)

Elelyso® (taliglucerase alfa) (Revised)

Medication Waste (Revised)

Member Cost-Share Waiver: Contraceptives (Revised)

Naglazyme® (galsulfase) (Revised)

Cytogam® (cytomegalovirus immune globulin, human) (Revised)

Aldurazyme® (laronidase) (Revised)

Ravicti® (glycerol phenylbutyrate) (Revised)