All Insurance Policy Changes (Page 165)

Continuing from page 164. 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 Equivalents (MME) edits (Revised)
Humana·Effective Feb 1, 2025
Humana revised its Opioid Utilization Program (MME edits) for South Carolina Medicaid, effective February 1, 2025. The policy enforces quantity limits and prior authorization requirements for all opioid medications based on morphine milligram equivalents (MME), with different thresholds for opioid-naive patients (>90 MME daily or >5 days supply) and opioid-tolerant patients (maximum 30-day supply). Billing teams must implement prior authorization workflows for doses exceeding these limits unless specific clinical criteria are met (cancer, sickle-cell disease, palliative care, substance use disorder treatment, long-term care residence, or prescriber medical necessity attestation).
Medium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (Revised)
Humana·Effective Jul 21, 2021
Humana Medicare Advantage revised its Zynlonta (loncastuximab tesirine-Ipyl) coverage policy on June 25, 2025. The policy maintains prior authorization requirements for this CD19-directed antibody used to treat relapsed/refractory large B-cell lymphoma in patients who have received 2+ prior systemic therapies. Key criteria include diagnosis confirmation (DLBCL or HGBL), relapsed/refractory disease status, and single-agent use. Claims will be denied without prior authorization and if patients have experienced disease progression on Zynlonta.
Medium impact
Accrufer™ (ferric maltol) (Revised)
Humana·Effective May 22, 2024
Humana has revised its Accrufer™ (ferric maltol) pharmacy coverage policy effective May 22, 2024. This is a prior authorization policy for commercial plans requiring documentation that members have iron deficiency, underlying causes have been treated, and they have failed or cannot tolerate ferrous-form oral iron products before approval. The policy applies to Accrufer capsules (30 mg iron) for iron deficiency treatment in adults.
Medium impact
Jemperli (dostarlimab-gxly) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Jemperli (dostarlimab-gxly) prior authorization policy effective September 24, 2025, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy covers three indications: frontline endometrial cancer (combination therapy), second-line+ endometrial cancer (monotherapy for dMMR cases), and dMMR solid tumors. A critical exclusion applies: prior disease progression on anti-PD-1/PD-L1 therapy disqualifies members. Billing teams must implement prior authorization requirements for all Jemperli claims under these plans.
Medium impact
Truseltiq (infigratinib) (Revised)
Humana·Effective May 22, 2024
Humana updated its Truseltiq (infigratinib) prior authorization policy on May 22, 2024, for Medicare Advantage and Commercial plans. The policy requires prior authorization for this FGFR2 inhibitor used to treat unresectable locally advanced or metastatic cholangiocarcinoma with FGFR2 fusion/rearrangement in previously treated patients. Initial approvals are limited to six-month durations, and patients with prior disease progression on FGFR2 inhibitors are excluded from coverage.
Medium impact
Exservan™ (riluzole) (Revised)
Humana·Effective Aug 18, 2021
Humana updated its Exservan (riluzole) oral film prior authorization policy for Medicare Advantage members with ALS, effective August 18, 2021 with a revision date of June 24, 2026. The policy requires prior authorization for Exservan and mandates that members must have previous riluzole tablet treatment AND a documented contraindication to tablets (such as impaired swallowing ability) to qualify for coverage of the oral film formulation.
Medium impact
Amivantamab Products (Rybrevant, Rybrevant Faspro) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Amivantamab (Rybrevant, Rybrevant Faspro) prior authorization policy effective January 28, 2026, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy clarifies coverage for four distinct NSCLC EGFR mutation scenarios with specific prior auth criteria; notably, Rybrevant Faspro (subcutaneous) is now explicitly differentiated from intravenous formulations with a critical warning against substitution due to different dosing and administration protocols.
Medium impact
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)
Humana·Effective Jul 23, 2025
Humana revised its prior authorization policy for Rylaze (asparaginase Erwinia chrysanthemi recombinant-rywn) effective July 23, 2025. The policy clarifies that coverage requires: (1) diagnosis of ALL or LBL, (2) documented Grade 2-4 hypersensitivity to prior Oncaspar treatment, and (3) use as part of multi-agent chemotherapy. Four serious adverse event exclusions apply: prior pancreatitis, thrombosis, hemorrhage, or disease progression with asparaginase-based therapy. Prior authorization remains required with 6-month approval duration for both initial and renewal requests.
Medium impact
Loreev XR® (lorazepam) (Revised)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage has revised its prior authorization policy for Loreev XR® (lorazepam extended-release capsules), effective February 25, 2026. The policy requires prior authorization for this medication with strict enrollment criteria: patient must have anxiety disorder diagnosis per DSM-5, prior treatment failure/intolerance to SSRIs/SNRIs/buspirone, prior treatment with generic lorazepam tablets, and current stable three-times-daily dosing with generic lorazepam. Initial and renewal approvals are limited to six-month periods.
Medium impact
Rezurock (belumosudil) (Revised)
Humana·Effective Sep 24, 2025
Humana Medicare Advantage updated its Rezurock (belumosudil) prior authorization policy effective September 24, 2025. The policy maintains existing coverage criteria for chronic graft-versus-host disease (cGVHD) requiring failure of at least two prior systemic therapies and a medical reason why Jakafi (Ruxolitinib) cannot be used. Key update includes a new exclusion criterion: members experiencing disease progression while on Rezurock are not eligible for continued coverage. Billing teams must implement prior authorization requirements for this pharmacy benefit.
Medium impact
Nexviazyme™ (avalglucosidase alfa-ngpt) Injection (Revised)
Humana·Effective May 27, 2026
Humana revised its prior authorization policy for Nexviazyme™ (avalglucosidase alfa-ngpt) effective May 27, 2026, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains two approval criteria: confirmed late-onset Pompe disease diagnosis and supporting lab/genetic testing (GAA enzyme deficiency or pathogenic GAA gene variants). This is a routine policy revision with no substantive coverage changes but requires verification of current authorization requirements.
Medium impact
Welireg (belzutifan) (Revised)
Humana·Effective May 27, 2026
Humana updated its prior authorization policy for Welireg (belzutifan) effective May 27, 2026. The policy covers three indications for Medicare Advantage members: von Hippel Lindau (VHL) disease with associated tumors, advanced renal cell carcinoma (RCC) after prior treatment failure, and pheochromocytoma/paraganglioma (PPGL) in patients 12 years and older. All approvals require monotherapy administration and prior authorization before dispensing.
Medium impact
Kerendia® (finerenone) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Kerendia (finerenone) prior authorization policy for Medicare Advantage plans effective November 26, 2025. The policy maintains existing approval criteria for two indications: CKD with type 2 diabetes (requiring ACE inhibitor or ARB use) and heart failure with LVEF ≥40%. Billing teams must ensure all Kerendia requests include required clinical documentation and meet specified approval criteria to avoid claim denials.
Medium impact
Kerendia® (finerenone) (Revised)
Humana·Effective Sep 25, 2024
Humana's Kerendia (finerenone) pharmacy coverage policy was revised on September 25, 2024. This is a prior authorization policy for commercial plans covering chronic kidney disease associated with type 2 diabetes. The policy requires prior authorization with four specific clinical criteria: CKD diagnosis with T2D, serum potassium ≤5.0 mEq/L, concurrent maximally tolerated ACE-I or ARB therapy, and prior treatment/contraindication/intolerance to SGLT2 inhibitors. Billing teams must ensure all Kerendia requests include documentation of these four criteria before submission to avoid claim denials.
Medium impact
Exkivity (mobocertinib) (Revised)
Humana·Effective Nov 17, 2021
Humana Medicare Advantage has revised its prior authorization policy for Exkivity (mobocertinib), a targeted therapy for metastatic non-small cell lung cancer with EGFR exon 20 insertion mutations. The policy requires prior authorization with four clinical criteria: locally advanced/metastatic NSCLC, documented EGFR exon 20 insertion mutation, disease progression on platinum-based therapy, and use as single-agent subsequent therapy. Coverage is approved for 6-month periods with renewal available.
Medium impact
Scemblix® (asciminib) (Revised)
Humana·Effective Dec 15, 2021
Humana updated its Scemblix (asciminib) pharmacy coverage policy for Medicare Advantage members effective December 15, 2021, with the most recent revision on April 22, 2026. The policy maintains prior authorization requirements for this tyrosine kinase inhibitor used to treat Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML) in chronic phase, covering newly diagnosed disease, previously treated disease, and disease with T315I mutation. Coverage is denied if the member experiences disease progression while on Scemblix.
Medium impact
Saphnelo™ (anifrolumab-fnia) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage revised its Saphnelo (anifrolumab-fnia) prior authorization policy effective May 27, 2026. The policy maintains existing coverage criteria for moderate-to-severe SLE patients on standard combination therapy, requires autoantibody confirmation (ANA, anti-dsDNA, anti-Sm), and mandates specialist prescribing. All Saphnelo formulations (IV solution, Pen auto-injector, and syringe) require prior authorization with plan year duration approvals.
Medium impact
Livmarli® (maralixibat) (Revised)
Humana·Effective Dec 17, 2025
Humana Medicare Advantage updated its Livmarli® (maralixibat) prior authorization policy on December 17, 2025, clarifying coverage criteria for cholestatic pruritus in Alagille Syndrome (ALGS) and Progressive Familial Intrahepatic Cholestasis (PFIC). The revision reinforces strict prior authorization requirements including specialist prescription, failed prior treatment, and specific diagnostic criteria (confirmed diagnosis with clinically significant pruritus and elevated serum bile acids). A critical new exclusion prohibits coverage for PFIC Type 2 patients with non-functional ABCB11 variants.
Medium impact
Aduhelm® (aducanumab-avwa) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Aduhelm (aducanumab-avwa) prior authorization policy for South Carolina Medicaid, effective November 26, 2025. The revision introduces stricter renewal criteria for continuation of therapy, including new ARIA (Amyloid-Related Imaging Abnormalities) monitoring thresholds and a requirement that providers attest potential benefits exceed risks. Initial approval remains 6 months, with renewals also at 6-month intervals.
Medium impact
Tivdak (tisotumab vedotin-tftv) (Revised)
Humana·Effective Aug 27, 2025
Humana revised its Tivdak (tisotumab vedotin-tftv) prior authorization policy effective August 27, 2025. The policy now applies to Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid for recurrent/metastatic cervical cancer treatment. Key change: Florida Medicaid requests are now exempt from the step therapy requirement (Keytruda trial), while Medicare and other state Medicaid plans still require documented medical reason for not using pembrolizumab first.
Medium impact
Xpovio® (selinexor) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage revised its Xpovio (selinexor) prior authorization policy effective January 28, 2026. The policy maintains coverage for multiple myeloma (MM) under two treatment pathways: (1) as monotherapy after 4+ prior therapies with specific refractoriness criteria, or (2) in combination with bortezomib and dexamethasone after 1+ prior therapy. It also covers relapsed/refractory DLBCL after 2+ lines of systemic therapy as monotherapy. Prior authorization is required for all uses, and claims will be denied if members have experienced disease progression on selinexor.
Low impact
Xenazine® (tetrabenazine) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Xenazine (tetrabenazine) pharmacy coverage policy for Medicare Advantage members with a revision date of June 24, 2026. The policy maintains prior authorization requirements for brand Xenazine when members have not previously tried or are intolerant to generic tetrabenazine. No substantive coverage criteria changes are documented in this revision; the policy continues to cover tetrabenazine for chorea associated with Huntington's disease with the same clinical and safety requirements.
Medium impact
Xeloda (capecitabine) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage revised its Xeloda (capecitabine) pharmacy coverage policy on December 17, 2025, establishing prior authorization requirements across 11 cancer indications with specific clinical criteria and a universal exclusion for severe renal impairment (creatinine clearance <30 mL/min). This is a maintenance revision that clarifies and consolidates coverage criteria for this chemotherapy agent.
Medium impact
Viscosupplements - Single Injection (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage updated its Viscosupplements - Single Injection prior authorization policy effective January 28, 2026. The policy requires prior authorization for Gel-One and Hymovis ONE intra-articular injections for knee osteoarthritis. Billing teams must verify members meet all three approval criteria: documented symptomatic knee OA, prior treatment/failure with specific agents (Durolane, Monovisc, or Synvisc-One), and 6-month interval for re-treatment. Step therapy requirements do not apply for Medicare Part B continuation requests within 365 days.
Medium impact
Viscosupplements - Multi Injection (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage updated its viscosupplement prior authorization policy effective January 28, 2026 (revision date). The policy maintains existing criteria requiring documented symptomatic knee osteoarthritis, prior treatment/failure with Orthovisc or Supartz FX (or continuation within 365 days for Part B), and 6-month intervals between retreatment cycles. No substantive coverage changes were made, but the policy was formally reviewed and re-issued, requiring billing teams to verify this is the current version in use.

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Archive by year

2023 2024 2025 2026

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

Zynlonta™ (loncastuximab tesirine-Ipyl) (Revised)

Accrufer™ (ferric maltol) (Revised)

Jemperli (dostarlimab-gxly) (Revised)

Truseltiq (infigratinib) (Revised)

Exservan™ (riluzole) (Revised)

Amivantamab Products (Rybrevant, Rybrevant Faspro) (Revised)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)

Loreev XR® (lorazepam) (Revised)

Rezurock (belumosudil) (Revised)

Nexviazyme™ (avalglucosidase alfa-ngpt) Injection (Revised)

Welireg (belzutifan) (Revised)

Kerendia® (finerenone) (Revised)

Kerendia® (finerenone) (Revised)

Exkivity (mobocertinib) (Revised)

Scemblix® (asciminib) (Revised)

Saphnelo™ (anifrolumab-fnia) (Revised)

Livmarli® (maralixibat) (Revised)

Aduhelm® (aducanumab-avwa) (Revised)

Tivdak (tisotumab vedotin-tftv) (Revised)

Xpovio® (selinexor) (Revised)

Xenazine® (tetrabenazine) (Revised)

Xeloda (capecitabine) (Revised)

Viscosupplements - Single Injection (Revised)

Viscosupplements - Multi Injection (Revised)