All Insurance Policy Changes (Page 160)

Continuing from page 159. 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
Non-Benzodiazepine Hypnotics (Revised)
Humana·Effective Jan 1, 2020
Humana updated its Non-Benzodiazepine Hypnotics pharmacy coverage policy (effective January 1, 2020, revised June 26, 2024) establishing a step therapy requirement for coverage. Members must have previous treatment within the past 12 months OR intolerance to zolpidem IR AND previous treatment within the past 12 months OR intolerance to either eszopiclone or zaleplon before newer agents (Belsomra, Dayvigo, Quviviq, etc.) are approved. This is a step therapy/prior authorization policy affecting 15 covered hypnotic medications.
Medium impact
Niacin-containing agents (Revised)
Humana·Effective Jan 24, 2024
Humana revised its niacin extended-release prior authorization policy effective January 24, 2024. The policy requires prior authorization for niacin ER tablets for commercial members with either severe hypertriglyceridemia (TG >500 mg/dL) or hyperlipidemia/mixed dyslipidemia, with mandatory evidence of prior treatment failure or contraindication to specific generic fibrates and statins before approval.
Medium impact
Mylotarg® (gemtuzumab ozogamicin) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana prior authorization policy for Mylotarg (gemtuzumab ozogamicin), a CD33-positive acute myeloid leukemia treatment, updated December 17, 2025. The policy applies to Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina) and requires prior authorization before dispensing. Key coverage criteria include diagnosis confirmation, CD33-positive disease documentation, and specific patient age/disease status requirements.
Medium impact
Mupirocin Topical Cream (Revised)
Humana·Effective Jan 1, 2020
This is a revision to Humana's Medicare Advantage step therapy policy for mupirocin 2% topical cream. The policy requires members to have previous treatment or documented intolerance with mupirocin topical ointment within the past 12 months before coverage of the cream formulation is approved. Coverage is approved for the plan year duration with renewal available.
Medium impact
Luxturna® (voretigene neparvovec-rzyl) (Revised)
Humana·Effective Jan 1, 2020
Humana updated the Luxturna (voretigene neparvovec-rzyl) prior authorization policy on December 17, 2025, for Medicaid coverage in Kentucky and South Carolina. The policy confirms coverage criteria for RPE65 mutation-associated retinal dystrophy with strict eligibility requirements including genetic confirmation, age 12 months to 65 years, and adequate retinal cell viability. Prior authorization is required for all requests with initial 6-month approval duration and 6-month renewal cycles.
Medium impact
Lutathera (lutetium Lu 177 dotatate) (Revised)
Humana·Effective Oct 8, 2025
Humana revised its Lutathera (lutetium Lu 177 dotatate) prior authorization policy effective October 8, 2025, affecting Medicare and four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia). The policy maintains existing approval criteria for neuroendocrine tumor treatment but includes updated dose modification protocols for adverse reactions, mandatory premedication management, and concomitant medication requirements. Billing teams must ensure all prior authorization requests comply with the three mandatory approval criteria and monitor for dose adjustments based on hematological, renal, and hepatic toxicity thresholds.
Medium impact
Lonsurf® (trifluridine and tipiracil) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Lonsurf (trifluridine/tipiracil) prior authorization policy effective December 17, 2025. This is a pharmacy prior authorization policy for Medicare Advantage members with metastatic colorectal cancer or gastric/gastroesophageal junction adenocarcinoma. The policy maintains existing approval criteria (6-month initial and renewal periods) but has been formally reviewed and updated as of the revision date.
Medium impact
Lidocaine 5% topical patch (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage revised its Lidocaine 5% topical patch prior authorization policy effective January 1, 2020, with the most recent revision dated November 26, 2025. The policy covers five indicated diagnoses (neuropathic cancer pain, post-herpetic neuralgia, diabetic neuropathy, chronic back pain, and hip/knee osteoarthritis pain) and requires prior authorization for all uses. Approval is granted for plan year duration for both initial and renewal requests when diagnostic criteria are met.
Low impact
Krystexxa® (pegloticase) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Krystexxa (pegloticase) prior authorization policy effective January 28, 2026, for Medicare, Medicaid-Kentucky, and Medicaid-South Carolina members. This is a routine policy update with no changes to coverage criteria, approval duration, or clinical requirements. The policy maintains six mandatory criteria for approval including chronic gout diagnosis, baseline uric acid >6 mg/dL, methotrexate co-therapy, G6PD deficiency screening, treatment refractoriness, and prior allopurinol exposure/contraindication.
High impact
Kadcyla (ado-trastuzumab emtansine) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Kadcyla (ado-trastuzumab emtansine) prior authorization policy effective January 1, 2020, with the most recent revision dated November 26, 2025. The policy covers two indications: metastatic breast cancer (HER2-positive, post-trastuzumab and taxane therapy) and early breast cancer (HER2-positive with residual invasive disease post-neoadjuvant therapy). The billing team must ensure all Kadcyla claims include prior authorization before submission and verify HER2 status documentation, treatment history, and exclusion criteria are met.
Medium impact
Jevtana® (cabazitaxel) (Revised)
Humana·Effective Jul 23, 2025
This is a revised Jevtana (cabazitaxel) prior authorization policy effective January 1, 2020, with the most recent revision dated July 23, 2025. The policy covers Jevtana for hormone-refractory metastatic prostate cancer in Medicare and four Medicaid state plans (Florida, Kentucky, South Carolina, Virginia). Billing teams must verify prior authorization requirements are met before claim submission, including confirmation of prior docetaxel treatment, concurrent corticosteroid use, and absence of contraindications (low neutrophil counts, severe hepatic impairment, or concomitant use with abiraterone acetate or enzalutamide).
Medium impact
Imlygic (talimogene laherparepvec) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Imlygic (talimogene laherparepvec) prior authorization policy effective January 1, 2020, with a revision date of June 24, 2026. The policy applies to Medicare and Medicaid (Florida, Kentucky, South Carolina) and establishes clear clinical criteria for coverage, including specific melanoma diagnoses, age requirements (18+), application method (intralesional injection), and four exclusion criteria. Billing teams must ensure prior authorization is obtained before dispensing this therapy and verify member eligibility against the defined criteria.
Medium impact
Idhifa® (enasidenib) (Revised)
Humana·Effective Oct 22, 2025
Humana has revised its Idhifa (enasidenib) prior authorization policy effective October 22, 2025. The policy now covers two distinct AML indications: relapsed/refractory AML with IDH2 mutation (as monotherapy or as part of repeating successful induction for late relapse >12 months) and newly diagnosed AML with IDH2 mutation in patients ineligible for intensive induction therapy. Both pathways require prior authorization with 6-month initial and renewal approval periods. Billing teams must implement these specific criteria in their authorization workflows immediately.
Medium impact
Hemlibra® (emicizumab-kxwh) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana prior authorization policy for Hemlibra (emicizumab-kxwh) for hemophilia A treatment, effective for Medicare and Medicaid in Kentucky. The policy establishes four mandatory approval criteria including severe hemophilia A diagnosis, step therapy requirements (with a 365-day continuation exception for Medicare Part B), physician attestation against extended half-life factor VIII use, and confirmation that Hemlibra will be used for prophylaxis. Two exclusions apply: other bleeding disorders and concurrent immune tolerance induction therapy.
Medium impact
Gralise® (gabapentin) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Gralise (gabapentin extended-release) coverage policy effective October 22, 2025, maintaining a step therapy requirement for Medicare Advantage members. Prior to Gralise approval, members must have documented previous treatment or intolerance to gabapentin AND at least one alternative agent (lidocaine 5% topical patches or pregabalin). This is a policy clarification/reaffirmation rather than a new restriction, with the same approval duration for initial and renewal periods on a plan year basis.
Medium impact
Gleostine (lomustine) (Revised)
Humana·Effective Jan 1, 2020
Humana has revised its Gleostine (lomustine) prior authorization policy effective January 1, 2020, with the most recent revision dated December 17, 2025. This Medicare Advantage pharmacy policy maintains prior authorization requirements for lomustine use in brain tumors and Hodgkin lymphoma, with specific approval criteria and exclusions that billing teams must verify before claim submission. The policy clarifies that prior authorization is required for all Gleostine dispensing, and claims lacking proper authorization will be denied.
Low impact
Gilotrif (afatinib) (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage has updated its Gilotrif (afatinib) prior authorization policy effective January 1, 2020, with a revision dated October 22, 2025. The policy maintains coverage for metastatic NSCLC patients with documented non-resistant EGFR mutations OR squamous cell histology after platinum-containing chemotherapy progression, requiring prior authorization with 6-month initial and renewal periods. This is a routine policy maintenance update with no substantive coverage changes from the original effective date.
Medium impact
Gazyva® (obinutuzumab) (Revised)
Humana·Effective Jan 1, 2020
This is a routine revision of Humana's Gazyva (obinutuzumab) prior authorization policy, effective January 1, 2020, with most recent updates on December 17, 2025. The policy covers three indications: Chronic Lymphocytic Leukemia (CLL), Follicular Lymphoma (FL), and Lupus Nephritis (LN) across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). No substantive coverage criteria changes are evident from the revision—the policy maintains existing approval requirements, exclusions, and renewal criteria for all three indications.
Medium impact
Firdapse® (amifampridine) (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage updated its Firdapse® (amifampridine) prior authorization policy on October 22, 2025. The policy maintains existing coverage requirements for Lambert-Eaton Myasthenic Syndrome (LEMS) treatment: specialist confirmation of diagnosis, clinical evaluation support (electromyography or VGCC auto-antibodies), and absolute exclusion for patients with seizure history. No substantive coverage changes are documented, but the recent revision requires verification that this is the current active policy before processing claims.
Medium impact
Fibrate Products (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Commercial pharmacy step therapy policy for fibrate products (fenofibrate and fenofibric acid derivatives) that was updated on January 24, 2024. The policy requires members to have prior treatment with generic fenofibrate micronized capsule (67mg, 134mg, or 200mg) OR generic fenofibrate tablet (48mg, 54mg, 145mg, or 160mg) before coverage of brand or alternative fibrate formulations is approved. The approval duration is for the initial plan year.
Medium impact
Emflaza® (deflazacort) (Revised)
Humana·Effective Jan 1, 2020
Humana updated its Emflaza (deflazacort) prior authorization policy for Medicare Advantage, effective January 1, 2020, with a revision date of October 22, 2025. The policy requires prior authorization for deflazacort and its brand equivalents (Jaythari, Pyquvi, Kymbee) for Duchenne Muscular Dystrophy treatment in patients who meet specific criteria: confirmed DMD diagnosis via genetic testing, muscle weakness onset before age 5, and prior prednisone treatment for at least 6 months with documented undesirable weight gain (>20% increase requiring dose reduction) or severe behavioral adverse effects. This is a routine policy update with no substantive coverage criteria changes from the original 2020 policy.
Medium impact
Crysvita® (burosumab) (Revised)
Humana·Effective Jan 1, 2020
Humana updated its Crysvita® (burosumab) prior authorization policy as of February 25, 2026. The policy covers two rare conditions: X-Linked Hypophosphatemia (XLH) in patients 6 months and older, and Tumor-Induced Osteomalacia (TIO) in patients 2 years and older. The revision maintains strict diagnostic criteria requiring FGF23 levels >30 pg/mL, reduced TmP/GFR ratios, and clinical symptoms, along with contraindications for patients with normal or elevated serum phosphorus levels. Billing teams must ensure prior authorization is obtained before dispensing this specialty medication.
Medium impact
Crotamiton Topical Products (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage updated its prior authorization policy for crotamiton topical products (Crotan, Eurax, Pruradik lotion/cream) effective January 1, 2020, with a revision date of November 26, 2025. The policy requires prior authorization for two distinct indications: (1) scabies treatment only after failure/contraindication/intolerance to both permethrin 5% cream AND oral ivermectin, and (2) pruritic skin treatment only after failure/contraindication/intolerance to both topical corticosteroids AND oral antihistamines. Both initial and renewal approvals are limited to one-year durations.
Medium impact
Clindagel® (clindamycin phosphate gel) (Revised)
Humana·Effective Jan 1, 2020
Humana revised its prior authorization policy for Clindagel® (clindamycin phosphate gel) effective January 1, 2020, with the most recent revision dated October 22, 2025. The policy requires prior authorization for topical clindamycin gel treatment of acne vulgaris, with approval contingent on members meeting two criteria: diagnosis of acne vulgaris AND prior treatment or intolerance with at least two specified topical products (adapalene gel, generic clindamycin gel, or erythromycin solution). Approval duration extends for the plan year with renewal available.
High impact
Cinvanti (aprepitant) emulsion (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Medicare Advantage prior authorization policy for Cinvanti (aprepitant) IV emulsion for chemotherapy-induced nausea and vomiting prevention. The policy requires concomitant corticosteroid and 5HT3 antagonist use, limits coverage to highly or moderately emetogenic chemotherapy, and explicitly excludes concurrent use with other NK1 antagonists (IV Emend, oral Emend 150mg, Varubi, Akynzeo). The revision date of April 22, 2026 indicates this is a very recent update requiring immediate billing team attention.

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Archive by year

2023 2024 2025 2026

Non-Benzodiazepine Hypnotics (Revised)

Niacin-containing agents (Revised)

Mylotarg® (gemtuzumab ozogamicin) (Revised)

Mupirocin Topical Cream (Revised)

Luxturna® (voretigene neparvovec-rzyl) (Revised)

Lutathera (lutetium Lu 177 dotatate) (Revised)

Lonsurf® (trifluridine and tipiracil) (Revised)

Lidocaine 5% topical patch (Revised)

Krystexxa® (pegloticase) (Revised)

Kadcyla (ado-trastuzumab emtansine) (Revised)

Jevtana® (cabazitaxel) (Revised)

Imlygic (talimogene laherparepvec) (Revised)

Idhifa® (enasidenib) (Revised)

Hemlibra® (emicizumab-kxwh) (Revised)

Gralise® (gabapentin) (Revised)

Gleostine (lomustine) (Revised)

Gilotrif (afatinib) (Revised)

Gazyva® (obinutuzumab) (Revised)

Firdapse® (amifampridine) (Revised)

Fibrate Products (Revised)

Emflaza® (deflazacort) (Revised)

Crysvita® (burosumab) (Revised)

Crotamiton Topical Products (Revised)

Clindagel® (clindamycin phosphate gel) (Revised)

Cinvanti (aprepitant) emulsion (Revised)