All Insurance Policy Changes (Page 154)

Continuing from page 153. 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
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.
Medium impact
Crofelemer Products (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage has revised its Crofelemer (Mytesi) prior authorization policy effective January 28, 2026. The policy maintains prior authorization requirements for non-infectious diarrhea treatment in HIV/AIDS patients on antiretroviral therapy, with four mandatory approval criteria: HIV/AIDS diagnosis, current antiretroviral therapy, non-infectious diarrhea diagnosis, and documented failure/intolerance to loperamide or diphenoxylate/atropine. Billing teams must ensure all Mytesi claims include prior authorization and meet all four criteria before submission.
Low impact
Signifor® (pasireotide) (Revised)
Humana·Effective Feb 25, 2026
Humana has revised its Signifor (pasireotide) prior authorization policy for Medicare Advantage members with Cushing's disease. The policy maintains existing approval criteria requiring diagnosis of Cushing's disease, documented failure or unsuitability of pituitary surgery, and absence of severe hepatic impairment. This 1-day-old revision (effective February 25, 2026) reflects a routine policy update with no material changes to coverage requirements or billing processes.
Medium impact
Sirturo® (bedaquiline) (Revised)
Humana·Effective Sep 24, 2025
This is a revised Humana Medicare Advantage prior authorization policy for Sirturo® (bedaquiline) for multidrug-resistant tuberculosis (MDR-TB), updated September 24, 2025. The policy requires prior authorization and maintains a 24-week approval duration for initial and renewal requests. The policy emphasizes bedaquiline's black box warnings for increased mortality and QT prolongation, requiring specific baseline and ongoing clinical monitoring before and during treatment.
Low impact
Cysteamine Ophthalmic Products (Cystaran®, Cystadrops®) (Revised)
Humana·Effective Aug 27, 2025
Humana has revised its prior authorization policy for cysteamine ophthalmic products (Cystaran® and Cystadrops®) effective August 27, 2025. The policy maintains the requirement for prior authorization for Medicare Advantage members with cystinosis who are using these products to treat corneal cystine crystal accumulation. Approval is granted for the plan year duration or as determined through clinical review for both initial and renewal requests.
Medium impact
Continuity of Care (Revised)
Humana·Effective May 27, 2026
Humana has revised its Continuity of Care policy for Ohio Medicaid pharmacy coverage, effective May 27, 2026. The policy allows overrides of utilization management (step therapy, prior authorization, non-preferred edits) for patients stable on pre-existing medications within 90 days of eligibility, but excludes experimental/investigational uses, off-label uses without evidence, and certain high-risk medication categories. Billing teams must implement validation logic to ensure requests meet all three criteria and flag exclusions before approving claims.
Low impact
Procysbi® (cysteamine) (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage updated its Procysbi® (cysteamine) prior authorization policy effective March 25, 2026. The policy requires prior authorization for this rare disease medication and mandates that members have a confirmed diagnosis of nephropathic cystinosis AND prior treatment or documented intolerance to Cystagon (cysteamine) before coverage approval. This is a routine revision to an existing policy with no substantive coverage changes from the original effective date.
Medium impact
Novarel®, Pregnyl® (human chorionic gonadotropin) (Revised)
Humana·Effective May 27, 2026
Humana revised its prior authorization policy for Novarel and Pregnyl (human chorionic gonadotropin) effective May 27, 2026. The policy maintains prior authorization requirements for four approvable indications (hypogonadotropic hypogonadism in males, prepubertal cryptorchidism, AIDS-related Kaposi's sarcoma, and hypospadias) while explicitly excluding coverage for infertility, obesity, erectile dysfunction, precocious puberty, and androgen-dependent neoplasms without additional clinical justification. Billing teams must ensure claims are submitted only for the four covered indications and implement prior authorization processes before the effective date.
Low impact
Dronabinol containing products (BRAND) (Revised)
Humana·Effective Aug 28, 2024
Humana updated its Dronabinol (Marinol/Syndros) prior authorization policy effective August 28, 2024. The policy maintains two coverage pathways: AIDS-related anorexia (requiring trials of megestrol acetate and generic dronabinol first) and chemotherapy-induced nausea/vomiting (requiring trials of generic dronabinol and another antiemetic agent first). This is a routine policy revision with no substantive changes to coverage criteria or billing requirements.
Low impact
Dronabinol (GENERIC) (Revised)
Humana·Effective Aug 28, 2024
Humana revised its Dronabinol (generic) prior authorization policy effective August 28, 2024. The policy maintains existing requirements for two indications: AIDS-related anorexia (requires trial/intolerance/contraindication to megestrol acetate) and chemotherapy-induced nausea/vomiting (requires trial/intolerance/contraindication to at least two other antiemetic agents). No substantive coverage criteria changes are documented; this appears to be a routine policy refresh/review.
Low impact
Alferon N® (interferon alfa-n3) (Revised)
Humana·Effective Feb 28, 2024
Humana revised its Alferon N (interferon alfa-n3) prior authorization policy for commercial plans, effective February 28, 2024. The policy requires prior authorization for intralesional treatment of condylomata acuminata in patients 18+ who have failed or are intolerant to imiquimod and other treatment modalities (surgery, laser, cryotherapy). Initial approval covers 8-week treatment durations. This is a routine policy update with no substantive changes to coverage criteria.
Medium impact
Vimizim® (elosulfase alfa) (Revised)
Humana·Effective Mar 6, 2014
This is a revised Humana prior authorization policy for Vimizim (elosulfase alfa) for treatment of Mucopolysaccharidosis IVA (MPS IVA; Morquio A Syndrome), updated January 28, 2026. The policy requires prior authorization and applies to Medicare, Medicaid in South Carolina, and Medicaid in Virginia. The single approval criterion is confirmed diagnosis of MPS IVA, with approvals granted for plan year durations for both initial and renewal requests.
Medium impact
Sylvant® (siltuximab) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Sylvant® (siltuximab) prior authorization policy effective November 26, 2025, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains strict eligibility criteria requiring multicentric Castleman's disease diagnosis with HIV and HHV-8 negative status, specific lab values (ANC ≥1.0 x 10⁹/L, platelets ≥75 x 10⁹/L, hemoglobin <17 g/dL for initial; platelets ≥50 x 10⁹/L for renewal), and 6-month approval periods. No substantive coverage changes were made, but the revision date indicates policy review and potential clarification of existing requirements.
Medium impact
Beleodaq® (belinostat) (Revised)
Humana·Effective Nov 26, 2025
Humana has revised its Beleodaq (belinostat) prior authorization policy effective November 26, 2025, covering Medicare and Medicaid members in Florida, Kentucky, and South Carolina. The policy requires prior authorization for belinostat treatment in relapsed or refractory peripheral T-cell lymphoma (PTCL), with specific exclusion criteria including disease progression on Beleodaq and concomitant use of other HDAC inhibitors. Initial and renewal approvals are valid for 6 months or as determined through clinical review.
Low impact
Cerdelga® (eliglustat) (Revised)
Humana·Effective Jun 26, 2024
Humana updated its Cerdelga (eliglustat) prior authorization policy on June 26, 2024, for Medicare Advantage and Commercial plans. The policy requires prior authorization for Cerdelga in adult patients with Type 1 Gaucher disease who have documented CYP2D6 metabolizer status (PM, EM, or IM) confirmed by FDA-approved genetic testing. No billing codes are specified in this pharmacy policy; requests must be submitted through Humana's PAL system.

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Archive by year

2023 2024 2025 2026

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)

Crofelemer Products (Revised)

Signifor® (pasireotide) (Revised)

Sirturo® (bedaquiline) (Revised)

Cysteamine Ophthalmic Products (Cystaran®, Cystadrops®) (Revised)

Continuity of Care (Revised)

Procysbi® (cysteamine) (Revised)

Novarel®, Pregnyl® (human chorionic gonadotropin) (Revised)

Dronabinol containing products (BRAND) (Revised)

Dronabinol (GENERIC) (Revised)

Alferon N® (interferon alfa-n3) (Revised)

Vimizim® (elosulfase alfa) (Revised)

Sylvant® (siltuximab) (Revised)

Beleodaq® (belinostat) (Revised)

Cerdelga® (eliglustat) (Revised)