All Insurance Policy Changes (Page 164)

Continuing from page 163. 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
Acitretin (Revised)
Humana·Effective Jul 23, 2025
Humana updated its Medicare Advantage prior authorization policy for Acitretin (revised 7/23/2025). The policy maintains existing coverage criteria requiring diagnosis of severe cutaneous psoriasis AND prior treatment failure/contraindication/intolerance to methotrexate or cyclosporine. No changes to approval duration are specified in the revised document. Billing teams must ensure all Acitretin requests include documented evidence of both criteria before submission.
Medium impact
Gimoti™ (metoclopramide) (Revised)
Humana·Effective Aug 27, 2025
Humana Medicare Advantage updated its prior authorization policy for Gimoti (metoclopramide nasal spray) on August 27, 2025. The policy requires prior authorization for Gimoti coverage in Medicare Advantage members with diabetic gastroparesis who have failed or are intolerant to generic metoclopramide. Billing teams must verify all Gimoti claims meet the two approval criteria and confirm members have no history of tardive dyskinesia or dystonic reactions before submission.
Medium impact
Enspryng® (satralizumab-mwge) (Revised)
Humana·Effective May 27, 2026
Humana revised its prior authorization policy for Enspryng® (satralizumab-mwge) for Neuromyelitis Optica Spectrum Disorder (NMOSD) effective May 27, 2026. The policy requires two mandatory criteria for approval: anti-aquaporin-4 (AQP4) antibody positivity and at least one core clinical characteristic of NMOSD. This applies to Medicare and Medicaid members in South Carolina and requires prior authorization before dispensing.
High impact
Opioid Utilization Program - Concurrent Use of Opioids and Benzodiazepines (COB) edits (Revised)
Humana·Effective Jan 1, 2025
Humana has revised its Opioid Utilization Program policy to mandate prior authorization for ALL concurrent use of opioids and benzodiazepines (both new and existing patients) across Medicare, Medicaid (SC, OK, VA), and LINET plans, effective January 1, 2025. The policy creates point-of-sale edits with soft rejects (Virginia Medicaid) or hard rejects (South Carolina Medicaid) that require pharmacist override codes or prior authorization approval, with limited exceptions for sickle cell disease, active cancer, hospice, long-term care residents, and cases where providers attest to benefit outweighing risks.
Medium impact
Danyelza® (naxitamab-gqgk) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its Danyelza (naxitamab-gqgk) prior authorization policy effective June 24, 2026, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy clarifies coverage criteria for this anti-GD2 monoclonal antibody used to treat relapsed/refractory high-risk neuroblastoma, requiring combination use with Leukine (sargramostim) and prior authorization for all claims. Key exclusions include monotherapy use and cases with documented disease progression on Danyelza.
Medium impact
Reltone™ (ursodiol capsule) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage revised its Reltone (ursodiol capsule) prior authorization policy effective April 22, 2026. The policy requires prior authorization for Reltone use in two indications: gallstone treatment (for radiolucent, noncalcified stones <20mm) and gallstone prevention (during rapid weight loss), with the requirement that members must have had previous treatment or intolerance with generic ursodiol tablets or 300mg capsules. Coverage is limited to plan-year durations with an important safety limitation that use beyond 24 months is not established.
Medium impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·Effective Feb 19, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Breyanzi (lisocabtagene maraleucel), a CAR-T cell therapy for relapsed/refractory B-cell lymphomas and leukemias. The policy was updated on February 19, 2026, and maintains strict approval criteria including documented prior therapy lines, disease refractoriness/relapse timing, age ≥18, concurrent lymphodepleting chemotherapy, and a lifetime maximum of one dose per member. Primary CNS lymphoma cases are excluded.
Medium impact
Tepmetko (tepotinib) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Tepmetko (tepotinib) prior authorization policy for Medicare Advantage members with a revision date of November 26, 2025. The policy requires prior authorization for this MET inhibitor in metastatic NSCLC with MET exon 14 skipping mutations. Key approval criteria require documented metastatic NSCLC with confirmed MET exon 14 skipping mutation, and the policy excludes members with prior disease progression on MET inhibitors.
Medium impact
Yescarta™ (axicabtagene ciloleucel) (Revised)
Humana·Effective May 1, 2026
Humana Kentucky Medicaid updated its Yescarta (axicabtagene ciloleucel) prior authorization policy effective May 1, 2026. The policy covers CAR-T cell therapy for relapsed/refractory large B-cell lymphoma (2L and 3L indications) and follicular lymphoma in adults ≥18 years. Key requirements include prior authorization through Corporate Transplant Department, use with lymphodepleting chemotherapy, and exclusions for prior CD-19 targeted therapy, active hepatitis B/C, HIV/AIDS, and prior allogeneic transplant. Maximum one dose per lifetime applies.
Medium impact
Verquvo® (vericiguat) (Revised)
Humana·Effective Apr 22, 2026
Humana has revised its Verquvo (vericiguat) prior authorization policy for Medicare Advantage members with heart failure. The policy maintains three strict approval criteria: symptomatic chronic heart failure (NYHA Class II-IV), left ventricular ejection fraction ≤45%, and a worsening cardiac event requiring hospitalization or IV diuretics within the past 6 months. This revision (dated April 22, 2026) reinforces the Black Box Warning regarding fetal harm and pregnancy prevention requirements.
Medium impact
Tecartus™ (brexucabtagene autoleucel) (Revised)
Humana·Effective May 1, 2026
This is a revised Medicaid (Kentucky) prior authorization policy for Tecartus (brexucabtagene autoleucel), a CAR-T cell therapy for relapsed/refractory mantle cell lymphoma and acute lymphoblastic leukemia in adults. The policy was last revised May 1, 2026 (1 day ago). Billing teams must ensure all Tecartus requests include prior authorization through Humana's Corporate Transplant Department and verify patient meets strict clinical criteria including age ≥18, disease status, and absence of specific contraindications (prior CAR-T therapy, active hepatitis B/C, HIV/AIDS, CNS lymphoma, or prior allogeneic transplant). Maximum one dose per lifetime applies.
Medium impact
Oxlumo® (lumasiran) (Revised)
Humana·Effective Sep 24, 2025
Humana Medicare Advantage updated its prior authorization policy for Oxlumo (lumasiran) on September 24, 2025. The policy maintains strict criteria requiring confirmed PH1 diagnosis via genetic testing or liver biopsy, elevated oxalate levels, specialist prescription, and no prior liver transplant. Initial and renewal approvals are for 6 months or plan year duration. Billing teams must ensure all Oxlumo requests include required clinical documentation before submission to avoid claim denials.
Medium impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·Effective May 1, 2026
Humana Kentucky Medicaid updated its Kymriah (tisagenlecleucel) prior authorization policy effective May 1, 2026, clarifying coverage criteria for three indications: diffuse large B-cell lymphoma (DLBCL), acute lymphoblastic leukemia (ALL), and follicular lymphoma. The policy maintains strict eligibility requirements including prior therapy lines, disease status, age limits, and multiple exclusions (prior gene therapy, prior anti-CD19 therapy, active hepatitis B/C, HIV/AIDS, and for lymphoma patients, prior allogeneic transplant). All approvals are limited to one dose per lifetime with 60-day authorization duration.
Medium impact
Cosela™ (trilaciclib) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Cosela (trilaciclib) prior authorization policy effective March 25, 2026. This policy covers the use of Cosela to decrease chemotherapy-induced myelosuppression in adult patients with extensive-stage small cell lung cancer receiving platinum/etoposide or topotecan-containing chemotherapy regimens. Prior authorization is required for all requests, with approval granted for the initial and renewal plan year duration or as clinically determined.
High impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·Effective May 1, 2026
This is a revision to Humana's Kentucky Medicaid prior authorization policy for Breyanzi® (lisocabtagene maraleucel), a CAR-T cell therapy for relapsed/refractory B-cell lymphomas and CLL/SLL. The policy outlines specific clinical criteria, exclusions, and a one-dose-per-lifetime approval limit for multiple indications. The revision date of May 1, 2026 indicates this is an updated version of the original April 21, 2021 policy.
Medium impact
Zypitamag® (pitavastatin) (Revised)
Humana·Effective May 1, 2021
Humana has revised its Zypitamag® (pitavastatin) pharmacy coverage policy effective May 1, 2021, with the most recent revision dated October 22, 2025. This is a step therapy policy for Medicare Advantage members with hyperlipidemia that provides automatic approval for patients with prior treatment on simvastatin, pravastatin, lovastatin, atorvastatin, or rosuvastatin. The policy includes important safety warnings regarding myopathy, rhabdomyolysis, immune-mediated necrotizing myopathy, and hepatic dysfunction that billing teams should communicate to providers.
Medium impact
Bempedoic Acid Products (Revised)
Humana·Effective Apr 1, 2026
Humana Medicare Advantage has revised its prior authorization policy for bempedoic acid products (Nexletol, Nexlizet) effective April 1, 2026. The policy maintains two coverage pathways: (1) hypercholesterolemia treatment after statin failure or statin intolerance, and (2) cardiovascular disease prevention in high-risk patients unable to tolerate statins. Prior authorization is required for both indications, with lipid level analysis required 8-12 weeks post-initiation.
Medium impact
Margenza (margetuximab-cmkb) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Margenza (margetuximab-cmkb) prior authorization policy effective September 24, 2025. The policy maintains coverage for metastatic HER2-positive breast cancer patients who have received at least 2 prior anti-HER2 regimens (with one in metastatic setting) and are receiving Margenza in combination with specific chemotherapy agents. The revision date change suggests updates to clinical criteria, references, or administrative requirements—review the full policy against your previous version to identify specific differences.
Medium impact
Lupkynis® (voclosporin) (Revised)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage updated its Lupkynis (voclosporin) prior authorization policy on February 25, 2026. The policy establishes four mandatory criteria for coverage: biopsy-proven class III/IV/V lupus nephritis, combination use with background immunosuppressive therapy, prohibition of concurrent cyclophosphamide use, and prescriber requirement for rheumatology/nephrology expertise. Prior authorization is required for all Lupkynis prescriptions with approval issued in plan year durations.
Medium impact
Fotivda (tivozanib) (Revised)
Humana·Effective Dec 17, 2025
Humana updated its Fotivda (tivozanib) prior authorization policy for Medicare Advantage members with relapsed or refractory advanced renal cell carcinoma. The policy requires prior authorization and confirms coverage criteria: diagnosis of advanced RCC, two prior systemic therapies, and use as a single agent. A new exclusion criterion denies approval if disease progression occurs on Fotivda. This is a revision to an existing policy (originally effective May 19, 2021) with the most recent update on December 17, 2025.
Medium impact
Bronchitol® (mannitol) (Revised)
Humana·Effective Dec 17, 2025
Humana Medicare Advantage revised its Bronchitol (mannitol) prior authorization policy effective December 17, 2025. The policy requires prior authorization for this inhaled mucolytic agent in cystic fibrosis patients, with mandatory Bronchitol Tolerance Testing (BTT) under healthcare provider supervision and concurrent use with short-acting bronchodilators (e.g., albuterol) as approval criteria.
Medium impact
Nulibry™ (fosdenopterin) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage updated its prior authorization policy for Nulibry (fosdenopterin) on November 26, 2025. The policy clarifies coverage for molybdenum cofactor deficiency Type A treatment with two approval pathways: initial 3-month approvals for members with pending genetic testing based on presumed diagnosis, and plan-year duration approvals for members with confirmed MOCS1 gene mutations. This is a newly revised policy requiring billing teams to understand and implement the dual approval duration structure.
Medium impact
Amondys 45 (casimersen) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Amondys 45 (casimersen) prior authorization policy effective December 17, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy establishes prior authorization requirements for this intravenous exon-skipping therapy in DMD patients, with specific clinical criteria for initial approval and renewal based on functional improvement or maintenance.
Medium impact
Abecma® (idecabtagene vicleucel) (Revised)
Humana·Effective May 1, 2026
Humana Medicaid (Kentucky) updated its prior authorization policy for Abecma (idecabtagene vicleucel), a CAR-T cell therapy for relapsed/refractory multiple myeloma. The revision effective May 1, 2026, maintains approval for 60 days with a lifetime maximum of one dose and requires documented criteria including prior treatment history, age ≥18, concurrent lymphodepleting chemotherapy, and exclusions for active hepatitis B/C, prior allogeneic transplant, or prior CAR-T therapy. All requests must be referred to the Corporate Transplant Department.
Medium impact
Abecma® (idecabtagene vicleucel) (Revised)
Humana·Effective Feb 19, 2026
Humana Medicare Advantage has revised its prior authorization policy for Abecma (idecabtagene vicleucel), a CAR-T cell therapy for relapsed/refractory multiple myeloma. The policy maintains strict eligibility criteria requiring at least two prior lines of therapy including specific drug classes, patient age ≥18, and lymphodepleting chemotherapy. Coverage is limited to one lifetime dose approved for 60 days. This revision was effective February 19, 2026, and billing teams must ensure prior authorization is obtained before claims submission.

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Archive by year

2023 2024 2025 2026

Acitretin (Revised)

Gimoti™ (metoclopramide) (Revised)

Enspryng® (satralizumab-mwge) (Revised)

Opioid Utilization Program - Concurrent Use of Opioids and Benzodiazepines (COB) edits (Revised)

Danyelza® (naxitamab-gqgk) (Revised)

Reltone™ (ursodiol capsule) (Revised)

Breyanzi® (lisocabtagene maraleucel) (Revised)

Tepmetko (tepotinib) (Revised)

Yescarta™ (axicabtagene ciloleucel) (Revised)

Verquvo® (vericiguat) (Revised)

Tecartus™ (brexucabtagene autoleucel) (Revised)

Oxlumo® (lumasiran) (Revised)

Kymriah™ (tisagenlecleucel) (Revised)

Cosela™ (trilaciclib) (Revised)

Breyanzi® (lisocabtagene maraleucel) (Revised)

Zypitamag® (pitavastatin) (Revised)

Bempedoic Acid Products (Revised)

Margenza (margetuximab-cmkb) (Revised)

Lupkynis® (voclosporin) (Revised)

Fotivda (tivozanib) (Revised)

Bronchitol® (mannitol) (Revised)

Nulibry™ (fosdenopterin) (Revised)

Amondys 45 (casimersen) (Revised)

Abecma® (idecabtagene vicleucel) (Revised)

Abecma® (idecabtagene vicleucel) (Revised)