All Insurance Policy Changes (Page 163)

Continuing from page 162. 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
Opioid Utilization Program - Morphine Milligram Equivalent (MME) edits (Revised)
Humana·Effective Jan 1, 2025
Humana revised its Opioid Utilization Program (MME) edits effective January 1, 2025, clarifying prior authorization requirements for opioid prescriptions. For Medicare Advantage members: doses >90 MME daily require prior auth if filled from >2 pharmacies and >2 prescribers; doses >200 MME require clinical review regardless. For LINET members: doses 90-200 MME require prior auth if from multiple pharmacies/prescribers; doses >200 MME always require clinical review. Approval is granted for cancer, sickle cell disease, palliative care, long-term care residents, or when medically necessary per prescriber attestation.
Medium impact
Ofev® (nintedanib) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Humana Medicare Advantage prior authorization policy for Ofev® (nintedanib) effective January 1, 2021, with the most recent revision dated June 24, 2026. The policy covers nintedanib for chronic fibrosing interstitial lung diseases with a progressive phenotype and requires prior authorization. No substantive coverage criteria changes are indicated from the revision, but billing teams must ensure all Ofev claims include proper prior authorization and meet the documented diagnostic and progressive phenotype criteria before dispensing.
Medium impact
Nuplazid® (pimavanserin) (Revised)
Humana·Effective Jan 1, 2021
Humana updated its Nuplazid® (pimavanserin) prior authorization policy for Medicare Advantage members on February 25, 2026. The policy requires prior authorization for this drug when used to treat hallucinations and delusions associated with Parkinson's disease psychosis. Three specific criteria must be met: member must be using Nuplazid for PD psychosis symptoms, psychosis must have appeared after PD diagnosis, and psychosis must not be related to other causes. The policy includes a black box warning clarifying that Nuplazid is not approved for dementia-related psychosis unless hallucinations are directly related to Parkinson's disease.
Medium impact
Nplate® (romiplostim) (Revised)
Humana·Effective Jan 1, 2021
Humana revised its Nplate (romiplostim) prior authorization policy for Medicare Advantage members, effective January 1, 2021, with the most recent revision dated April 22, 2026. The policy maintains prior authorization requirements for two indications: chronic ITP (requiring platelet count <50 x10⁹/L and documented corticosteroid failure/intolerance) and Hematopoietic Syndrome of Acute Radiation Syndrome (HS-ARS). Initial and renewal approvals are limited to 3-month durations. Billing teams must ensure all requests include required clinical documentation and platelet count verification before submission.
Medium impact
Nerlynx (neratinib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Nerlynx (neratinib) pharmacy coverage policy effective January 1, 2026. This is a prior authorization policy for Medicare Advantage members with HER2-positive breast cancer (early-stage in extended adjuvant setting or metastatic). Key requirements include documented HER2+ disease, completion of prior trastuzumab therapy (early-stage), and specific combination therapy for metastatic cases. The policy excludes members with disease progression on Nerlynx and limits early-stage treatment to one year maximum.
Medium impact
Nascobal® (cyanocobalamin) (Revised)
Humana·Effective May 22, 2024
Humana updated its Nascobal (cyanocobalamin) nasal spray prior authorization policy on May 22, 2024. The policy establishes clear approval criteria for two distinct indications: (1) pernicious anemia patients in remission from injectable B12 therapy with no nervous system involvement and injectable intolerance, and (2) patients with dietary, drug-induced, or malabsorption-related B12 deficiency who cannot tolerate injectable forms. Prior authorization is required for all Nascobal prescriptions under this commercial policy.
Medium impact
Lisdexamfetamine Products (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage has updated its prior authorization policy for lisdexamfetamine products (Vyvanse, Arynta, generic lisdexamfetamine). The policy maintains two distinct approval pathways: one for Binge Eating Disorder (BED) requiring age 18+ and moderate-to-severe diagnosis, and one for ADHD/ADD requiring age 6+ and prior failure/contraindication/intolerance to long-acting stimulants. All prescriptions require prior authorization with plan-year approval duration.
Medium impact
Letairis® (ambrisentan) (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage revised its Letairis (ambrisentan) prior authorization policy effective January 1, 2021, with the most recent revision dated October 22, 2025. The policy maintains PA requirements for PAH treatment, requiring confirmation of WHO Group I PAH diagnosis via right heart catheterization, and mandates previous treatment/intolerance/contraindication documentation for brand requests. Idiopathic pulmonary fibrosis is excluded from coverage.
High impact
Lemtrada® (alemtuzumab) (Revised)
Humana·Effective Oct 22, 2025
Lemtrada (alemtuzumab) prior authorization requirements were revised effective October 22, 2025 for Humana Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina plans. The policy maintains the requirement that members must have a diagnosis of relapsing-form MS and inadequate response to at least two alternative MS therapies (one must be Ocrevus or Ocrevus Zunovo), with important exceptions noted for Medicare Part D and Medicaid requests where prior Ocrevus treatment does not apply. Billing teams must verify current prior auth criteria before processing claims, as the policy includes complex step-therapy requirements with plan-type specific carve-outs.
Medium impact
Ketoconazole tablet (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage has revised its ketoconazole tablet prior authorization policy effective January 1, 2021, with a recent revision date of April 22, 2026. The policy requires prior authorization for ketoconazole tablets used to treat systemic fungal infections (blastomycosis, coccidioidomycosis, histoplasmosis, paracoccidioidomycosis, chromomycosis) and for transplanted organ rejection prophylaxis when used concurrently with cyclosporine immunosuppressant therapy. Approval is granted in plan year durations or through clinical review, with emphasis on hepatotoxicity and QT prolongation warnings.
High impact
Growth Hormone (Revised)
Humana·Effective Aug 27, 2025
Humana has revised its Growth Hormone (GH) therapy coverage policy for Medicare Advantage, effective January 1, 2021, with major updates as of August 27, 2025. The policy establishes comprehensive prior authorization requirements for 17 GH products across pediatric and adult indications, with specific diagnostic criteria, stimulation test requirements, and preferred product designation (Omnitrope). Billing teams must implement prior authorization workflows and ensure claims include required clinical documentation for diagnosis confirmation.
Medium impact
Foot Bath Medications (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage has revised its Foot Bath Medications policy (effective 1/1/2021, revised 5/28/2025) to require that foot bath/soak medications meet label or compendia-supported indications to be considered medically necessary. Claims for common foot bath medications (budesonide, ciclopirox, clindamycin phosphate, fluocinonide, ketoconazole, linezolid, nystatin, vancomycin) dispensed without approved compendia support will be rejected with error code 88 (NCPDP) or 527 (internal) and require clinical pharmacy review for coverage determination.
Medium impact
Flector®, Licart™ (diclofenac epolamine patch 1.3%) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Medicare Advantage prior authorization policy for Flector® and Licart™ (diclofenac epolamine patch 1.3%) effective January 1, 2021, with the most recent revision dated June 24, 2026. The policy requires prior authorization for these topical NSAID patches and limits coverage to acute pain from minor strains, sprains, and contusions in patients 6 years and older. Key contraindications include hypersensitivity to diclofenac, peri-operative CABG pain, aspirin/NSAID reactions, late pregnancy, and history of ulcer disease or GI bleeding.
Medium impact
Ezetimibe-Containing Products (Revised)
Humana·Effective May 22, 2024
Humana revised its Ezetimibe-Containing Products step therapy policy effective May 22, 2024. The policy requires members to have prior treatment with two generic statins (atorvastatin, lovastatin, pravastatin, simvastatin, or rosuvastatin) before coverage of Zetia or Vytorin products. This is a reconfirmation/clarification of existing step therapy requirements for commercial plans, with approval granted for the initial plan year duration.
Medium impact
Evista (raloxifene) (Revised)
Humana·Effective Mar 27, 2024
Humana revised its Evista (raloxifene) pharmacy coverage policy effective March 27, 2024. This is a step therapy policy requiring members to have prior treatment with or documented intolerance to at least one of the following agents (raloxifene, alendronate, ibandronate, or tamoxifen) before Evista coverage is approved. The policy includes important contraindications (active/past venous thromboembolism) and warnings (increased stroke risk in specific populations, not recommended for premenopausal women or cardiovascular prevention).
Medium impact
Equetro® (carbamazepine) (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage updated its Equetro® (carbamazepine) extended-release pharmacy coverage policy with a revision date of February 25, 2026. The policy maintains prior authorization requirements for three indications: seizures (requiring failure of generic carbamazepine plus one other antiepileptic agent), acute manic/mixed bipolar I episodes (requiring prior generic carbamazepine treatment), and trigeminal neuralgia (requiring prior generic carbamazepine treatment). All approvals are valid for the plan year with renewal at plan year duration.
Low impact
Duobrii® (halobetasol propionate and tazarotene) (Revised)
Humana·Effective Jan 1, 2021
Humana updated its prior authorization policy for Duobrii (halobetasol propionate and tazarotene) lotion for plaque psoriasis, effective January 1, 2021, with a revision date of February 25, 2026. The policy requires prior authorization and mandates that members have a diagnosis of plaque psoriasis AND previous treatment with, intolerance, or contraindication to tazarotene topical cream before approval. This is a routine policy maintenance update with no substantive coverage changes from the original effective date.
Medium impact
Doxycycline Antibiotics (Revised)
Humana·Effective Jan 1, 2021
This is a Step Therapy policy revision for doxycycline antibiotics (effective 1/1/2021, revised 7/23/2025) on Humana Medicare Advantage plans. The policy requires members to have previous treatment or documented intolerance with oral immediate-release doxycycline before coverage of delayed-release or brand formulations. Billing teams must verify step therapy compliance before submitting claims for affected doxycycline products to avoid denials.
Medium impact
Dopamine Agonists (Revised)
Humana·Effective Jan 1, 2021
Humana's Dopamine Agonists policy (Mirapex ER, pramipexole ER, ropinirole ER) was revised on June 26, 2024, and remains a step therapy requiring members to try or be unable to use immediate-release formulations (pramipexole IR and ropinirole IR) before approval for extended-release versions. This is a commercial plan policy affecting Parkinson's disease treatment. The policy confirms step therapy requirements but does not appear to introduce new restrictions beyond the original January 1, 2021 effective date.
Medium impact
Coreg CR® (carvedilol ER) (Revised)
Humana·Effective May 22, 2024
Humana revised its step therapy policy for Coreg CR® (carvedilol ER) effective May 22, 2024. The policy requires members to have prior treatment with at least two generic beta blockers (carvedilol tablet, atenolol tablet, or metoprolol tartrate/succinate) before Coreg CR coverage is approved. This is a step therapy requirement that affects pharmacy coverage for both brand-name Coreg CR and generic carvedilol phosphate ER.
Medium impact
Compounded Medications (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage has updated its compounded medications policy (effective 1/1/2021, revised 7/23/2025) to clarify coverage criteria for compounded drugs that reject with error codes 307 or 524. Coverage requires: (1) rejection with specific error codes, (2) medication meets Part D drug definition with compendia support, and (3) compounded in a compendia-supported dosage form. Billing teams must screen compounded medication claims against the exclusion list and route non-compliant claims for clinical pharmacy review.
Medium impact
Calquence® (acalabrutinib) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage revised its Calquence (acalabrutinib) prior authorization policy effective April 22, 2026. The policy maintains coverage for mantle cell lymphoma (MCL) with specific treatment history requirements and chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), with a key exclusion: members who have experienced disease progression while on or after Calquence are not approved. Billing teams must verify prior authorization requirements before dispensing and confirm members meet all clinical criteria.
Medium impact
Cabometyx (cabozantinib) (Revised)
Humana·Effective Jan 1, 2021
Humana Medicare Advantage revised its Cabometyx (cabozantinib) prior authorization policy effective January 1, 2021, with the most recent revision dated February 25, 2026. The policy maintains coverage criteria for four oncology indications: hepatocellular carcinoma (requires prior sorafenib treatment), renal cell carcinoma (as monotherapy or with nivolumab), thyroid cancer (age 12+, post-VEGF therapy, radioactive iodine refractory/ineligible), and neuroendocrine tumors (age 12+). All indications require prior authorization and exclude coverage if disease progression occurs on cabozantinib.
Medium impact
Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Medicare Advantage prior authorization policy for bexarotene products (Targretin and generic bexarotene) used to treat cutaneous T-cell lymphoma (CTCL). The policy was last revised on July 23, 2025 (1 day old) and maintains prior authorization requirements for both oral capsules and topical gel formulations. Key clinical criteria remain: bexarotene must be used as primary treatment OR the patient must have failed/been intolerant to at least one prior CTCL therapy. Pregnant members are excluded. The billing team must ensure all bexarotene prescriptions undergo prior authorization before dispensing.
Medium impact
Auryxia (ferric citrate) (Revised)
Humana·Effective Jan 1, 2021
Humana revised its Auryxia (ferric citrate) prior authorization policy, effective January 1, 2021, with updates finalized March 22, 2023. The policy maintains two distinct approval pathways: (1) for hyperphosphatemia in dialysis patients requiring prior treatment failure/intolerance with calcium acetate AND sevelamer carbonate, and (2) for iron deficiency anemia in non-dialysis CKD patients. Both indications require prior authorization before coverage. The policy emphasizes iron parameter monitoring and contraindication screening for hemochromatosis.

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Archive by year

2023 2024 2025 2026

Opioid Utilization Program - Morphine Milligram Equivalent (MME) edits (Revised)

Ofev® (nintedanib) (Revised)

Nuplazid® (pimavanserin) (Revised)

Nplate® (romiplostim) (Revised)

Nerlynx (neratinib) (Revised)

Nascobal® (cyanocobalamin) (Revised)

Lisdexamfetamine Products (Revised)

Letairis® (ambrisentan) (Revised)

Lemtrada® (alemtuzumab) (Revised)

Ketoconazole tablet (Revised)

Growth Hormone (Revised)

Foot Bath Medications (Revised)

Flector®, Licart™ (diclofenac epolamine patch 1.3%) (Revised)

Ezetimibe-Containing Products (Revised)

Evista (raloxifene) (Revised)

Equetro® (carbamazepine) (Revised)

Duobrii® (halobetasol propionate and tazarotene) (Revised)

Doxycycline Antibiotics (Revised)

Dopamine Agonists (Revised)

Coreg CR® (carvedilol ER) (Revised)

Compounded Medications (Revised)

Calquence® (acalabrutinib) (Revised)

Cabometyx (cabozantinib) (Revised)

Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)

Auryxia (ferric citrate) (Revised)