All Insurance Policy Changes (Page 157)

Continuing from page 156. 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
Nuvigil® (armodafinil) (Revised)
Humana·Effective Jan 1, 2018
Humana Medicare Advantage has revised its Nuvigil (armodafinil) prior authorization policy effective January 1, 2018, with the most recent revision dated November 26, 2025. The policy requires prior authorization for brand Nuvigil requests and mandates documented previous treatment or intolerance to armodafinil or modafinil before approval. Coverage is limited to excessive daytime sleepiness associated with narcolepsy, obstructive sleep apnea, or shift-work sleep disorder.
Medium impact
Northera® (droxidopa) (Revised)
Humana·Effective Jan 1, 2018
Humana has revised its Northera® (droxidopa) prior authorization policy effective January 1, 2018, with the most recent revision dated November 26, 2025. The policy requires prior authorization for droxidopa/Northera when treating neurogenic orthostatic hypotension (NOH), with mandatory criteria including diagnosis confirmation and documented failure or intolerance to fludrocortisone or midodrine. This is a routine policy refresh with no substantive coverage changes indicated.
Low impact
Horizant® (gabapentin enacarbil) (Revised)
Humana·Effective Jan 28, 2026
Humana updated its Horizant (gabapentin enacarbil) prior authorization policy effective January 28, 2026. The policy maintains existing coverage criteria for two indications: Restless Legs Syndrome (RLS) requires trial/intolerance/contraindication to both ropinirole AND pramipexole; Postherpetic Neuralgia (PHN) requires prior gabapentin treatment plus either pregabalin or lidocaine topical patch. This is a revision to a policy originally effective January 1, 2018, with no substantive clinical changes in approval criteria.
Medium impact
Solosec® (secnidazole) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage has updated its Solosec (secnidazole) prior authorization policy effective April 22, 2026. The policy maintains strict prior authorization requirements for bacterial vaginosis and trichomoniasis treatment, requiring documented failure, contraindication, or intolerance to first-line agents (metronidazole and clindamycin for BV; metronidazole and tinidazole for trichomoniasis) before Solosec can be approved. This is a revision of the existing policy rather than a new coverage change.
Medium impact
Prevymis™ (letermovir) (Revised)
Humana·Effective Mar 25, 2026
This is a revised Prevymis (letermovir) prior authorization policy effective March 25, 2026, covering CMV prophylaxis in two transplant populations: CMV-seropositive allogeneic HSCT recipients (age ≥6 months, weight ≥6kg, initiated within 28 days post-transplant) and high-risk kidney transplant recipients (D+/R-, age ≥12 years, weight ≥40kg, with documented medical reason for valganciclovir failure). Prior authorization is required for all Prevymis formulations across Kentucky, South Carolina, and Virginia Medicaid programs, with initial and renewal approvals limited to 12 months or clinical review determination.
Medium impact
Sinuva® (mometasone furoate) sinus implant (Revised)
Humana·Effective Jun 24, 2026
Humana revised its Sinuva® (mometasone furoate) sinus implant prior authorization policy effective June 24, 2026, covering Medicare and Medicaid plans in Florida, Kentucky, South Carolina, and Virginia. The policy requires prior authorization for all Sinuva implant requests and mandates that patients meet two criteria: diagnosed chronic rhinosinusitis with nasal polyps (CRSwNP) and age 18 or older. Billing teams must implement prior authorization workflows immediately for these specific state Medicaid programs and Medicare plans to prevent claim denials.
Medium impact
Osmolex ER™ (amantadine extended release) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Osmolex ER (amantadine extended release) prior authorization policy for Medicare Advantage members on November 26, 2025. The policy requires prior authorization for coverage of Osmolex ER in two indications: Parkinson's disease and drug-induced extrapyramidal reactions. For both conditions, members must demonstrate tolerance to at least 100mg of immediate-release amantadine and inadequate symptom improvement on immediate-release amantadine before the extended-release formulation will be approved.
Medium impact
Palynziq™ (pegvaliase-pqpz) Injection (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Palynziq (pegvaliase-pqpz) prior authorization policy effective January 28, 2026, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains three strict approval criteria requiring confirmed PKU diagnosis with specific lab testing (plasma amino acid analysis and pterin/DHPR assay), plus documented uncontrolled phenylalanine levels >600 micromol/L despite existing management. All claims require prior authorization with approvals granted in plan year durations for both initial and renewal requests.
Medium impact
Kapspargo™ Sprinkle (metoprolol succinate) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Kapspargo™ Sprinkle (metoprolol succinate) pharmacy coverage policy effective November 26, 2025. This is a step therapy policy requiring members to have prior treatment with at least two generic beta blockers (carvedilol, atenolol, or metoprolol tartrate/succinate) before Kapspargo coverage is approved. The policy applies to Medicare Advantage plans and includes contraindications for severe bradycardia, heart block, sick sinus syndrome without pacemaker, cardiogenic shock, or decompensated heart failure.
High impact
Florida Statute 456.44(5)(a) Opioid Days' Supply Limitation (Revised)
Humana·Effective Nov 27, 2024
Florida Medicaid updated its opioid days' supply limitation policy effective November 27, 2024. Schedule II opioids for acute pain are limited to 3 days (or 7 days with documented exception), Schedule III-V opioids to 14 days for acute pain, and all opioids to 30 days for non-acute/chronic pain. Prescribers must indicate 'Acute Pain Exception' or 'Non-Acute Pain' on prescriptions to override defaults, and certain diagnoses (cancer, sickle cell, hospice, terminal illness, serious traumatic injury) are excluded from acute pain limitations.
Medium impact
Galafold®(migalastat) (Revised)
Humana·Effective Dec 17, 2025
Humana Medicare Advantage updated its Galafold (migalastat) pharmacy coverage policy effective December 17, 2025. The policy maintains prior authorization requirements for Fabry disease treatment but clarifies that patients must have a confirmed diagnosis AND a GLA variant amenable to migalastat therapy as validated by GLP HEK assay. This is a revision to the original September 26, 2018 policy with no substantive coverage changes, but billing teams must ensure prior authorization requests include GLP HEK assay confirmation before claim submission.
Medium impact
Poteligeo® (mogamulizumab-kpkc) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Poteligeo (mogamulizumab-kpkc) prior authorization policy effective January 28, 2026, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains prior auth requirements for this oncologic monoclonal antibody used in relapsed/refractory mycosis fungoides or Sézary syndrome, with approval limited to 6-month intervals when used as sole systemic therapy. Key clinical criteria and exclusions remain in place, including denial of coverage for members experiencing disease progression on the drug.
Medium impact
Orilissa® (elagolix) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage revised its Orilissa (elagolix) prior authorization policy effective April 22, 2026. The policy maintains existing coverage criteria for endometriosis pain management but clarifies treatment duration limits: maximum 6 months at 200mg dosing or 24 months at 150mg dosing. All prior authorization requirements and clinical criteria remain unchanged from the original October 2018 policy.
Medium impact
Mulpleta® (lusutrombopag) (Revised)
Humana·Effective Apr 22, 2026
Humana updated its Mulpleta® (lusutrombopag) prior authorization policy for Medicare Advantage members on April 22, 2026. The policy requires prior authorization for this thrombocytopenia treatment in chronic liver disease patients scheduled for procedures. All three approval criteria must be met: chronic liver disease diagnosis, scheduled procedure requiring platelet transfusion, and initiation 8-14 days before the procedure. Initial and renewal approvals are granted for 3-month periods.
Medium impact
Azedra® (iobenguane I 131) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Azedra (iobenguane I 131) prior authorization policy for Medicaid and Medicare in Virginia, effective December 17, 2025. The policy maintains requirements for prior authorization before dispensing this radioactive therapeutic agent for unresectable/metastatic pheochromocytoma and paraganglioma, requiring documentation of positive iobenguane scan, patient age ≥12 years, prior inorganic iodine administration, and absence of contraindicated medications or severe renal impairment. No substantive coverage criteria changes are documented, but the revision date indicates a recent policy review that may include updated clinical references or administrative language.
Medium impact
Tiglutik® (riluzole) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its Tiglutik (riluzole) oral suspension prior authorization policy effective June 24, 2026. The policy requires prior authorization for Medicare Advantage members with ALS who have previously failed riluzole tablets AND have a documented contraindication (such as impaired swallowing ability). This is a restrictive criteria requiring documented prior tablet use and specific contraindication before approval.
Medium impact
Libtayo® (cemiplimab-rwlc) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Libtayo (cemiplimab-rwlc) prior authorization policy effective December 17, 2025, covering four indications: cutaneous squamous cell carcinoma, adjuvant CSCC, basal cell carcinoma, and NSCLC. The policy applies to Medicare, Medicaid (Florida, Kentucky, South Carolina), and requires prior authorization for all covered indications with specific clinical criteria and exclusions based on prior PD-1/PD-L1 inhibitor use.
Low impact
Copiktra™ (duvelisib) (Revised)
Humana·Effective Dec 17, 2025
Humana updated its Copiktra (duvelisib) prior authorization policy for Medicare Advantage plans, effective December 17, 2025. The policy requires prior authorization for Copiktra use in relapsed/refractory CLL/SLL patients as monotherapy, with an exclusion for patients with prior PI3K inhibitor progression. This is a routine policy revision with no substantive coverage changes from the original 2018 policy.
Medium impact
Triptans (Revised)
Humana·Effective Jan 1, 2019
This is a revised Humana Medicare Advantage step therapy policy for triptan medications (effective January 1, 2019, revised April 22, 2026). The policy requires patients to have a trial with TWO of three generic triptan products (sumatriptan, rizatriptan, or naratriptan) before coverage of branded or alternative triptan formulations. The policy covers 15 triptan products across multiple delivery methods and includes specific contraindications and warnings related to cardiovascular and cerebrovascular conditions.
Medium impact
Topical Rosacea Products (Revised)
Humana·Effective Jan 1, 2019
Humana Medicare Advantage revised its Step Therapy policy for topical rosacea products effective January 1, 2019, with the most recent revision dated December 17, 2025. The policy requires members to have prior treatment with topical metronidazole before coverage of other topical rosacea agents (Noritate, Metrogel, Rosadan, Finacea, Mirvaso, Soolantra, Rhofade, Epsolay, and their generic equivalents). Billing teams must enforce this step therapy requirement by obtaining documentation of metronidazole trial before approving claims for alternative topical rosacea products.
Medium impact
Topical Rosacea Products (Revised)
Humana·Effective Feb 28, 2024
Humana has revised its Topical Rosacea Products pharmacy coverage policy effective February 28, 2024, implementing a step-therapy requirement for 11 topical rosacea medications. The policy now requires members to have documented previous treatment with topical metronidazole before coverage approval for alternative agents like Soolantra, Rhofade, Mirvaso, Finacea, and others.
Medium impact
Simponi ARIA (golimumab) (Revised)
Humana·Effective Aug 27, 2025
Humana revised its Simponi ARIA (golimumab) prior authorization policy for Medicaid in South Carolina, effective August 27, 2025. The policy maintains prior authorization requirements for four indications (ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis) with specific criteria for age, prior therapy, and contraindications. Key requirement: all indications prohibit combination therapy with other biologics, and rheumatoid arthritis patients must receive concomitant methotrexate unless contraindicated.
High impact
Pediatric Antipsychotic Utilization Program (Revised)
Humana·Effective Apr 15, 2026
Humana has revised its Pediatric Antipsychotic Utilization Program (effective April 15, 2026) establishing stricter prior authorization requirements for all antipsychotic medications in pediatric patients aged <6 years (requires compendia-supported diagnosis) and ≥6 years (standard coverage), plus new restrictions on concurrent antipsychotic use in patients ≥6 years. This policy applies to Florida, South Carolina, Oklahoma, and Virginia Medicaid plans and affects 60+ antipsychotic formulations across typical and atypical classes.
High impact
Opioid Days' Supply Limitation (Revised)
Humana·Effective Oct 30, 2024
Humana Medicare Advantage has revised its opioid days' supply limitation policy effective October 30, 2024. The policy enforces strict quantity limits: opioid-naive patients are limited to 7 days' supply for acute pain, and opioid-tolerant patients are limited to 30 days' supply for non-acute pain (31 days for long-term care residents). Multiple clinical exceptions exist for cancer, sickle-cell disease, palliative care, and other qualifying diagnoses. Billing teams must ensure claims comply with these limits or face denials at point-of-sale.
Medium impact
Non-Formulary Exceptions (Revised)
Humana·Effective Jan 1, 2019
This is a revision to Humana's Non-Formulary Exceptions policy for Medicare Part D coverage, effective January 1, 2019, with the most recent revision dated June 24, 2026. The policy establishes procedures for members and physicians to request coverage of prescription drugs not included on Humana's formulary, with decision timeframes of 72 hours standard (24 hours expedited) and specific requirements for physician supporting statements. Key updates clarify that approved exceptions remain valid for the remainder of the plan year without requiring refill reauthorization, and Humana may limit days' supply to one month for specialty medications, opioids, and benzodiazepines.

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Archive by year

2023 2024 2025 2026

Nuvigil® (armodafinil) (Revised)

Northera® (droxidopa) (Revised)

Horizant® (gabapentin enacarbil) (Revised)

Solosec® (secnidazole) (Revised)

Prevymis™ (letermovir) (Revised)

Sinuva® (mometasone furoate) sinus implant (Revised)

Osmolex ER™ (amantadine extended release) (Revised)

Palynziq™ (pegvaliase-pqpz) Injection (Revised)

Kapspargo™ Sprinkle (metoprolol succinate) (Revised)

Florida Statute 456.44(5)(a) Opioid Days' Supply Limitation (Revised)

Galafold®(migalastat) (Revised)

Poteligeo® (mogamulizumab-kpkc) (Revised)

Orilissa® (elagolix) (Revised)

Mulpleta® (lusutrombopag) (Revised)

Azedra® (iobenguane I 131) (Revised)

Tiglutik® (riluzole) (Revised)

Libtayo® (cemiplimab-rwlc) (Revised)

Copiktra™ (duvelisib) (Revised)

Triptans (Revised)

Topical Rosacea Products (Revised)

Topical Rosacea Products (Revised)

Simponi ARIA (golimumab) (Revised)

Pediatric Antipsychotic Utilization Program (Revised)

Opioid Days' Supply Limitation (Revised)

Non-Formulary Exceptions (Revised)