All Insurance Policy Changes (Page 166)

Continuing from page 165. 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
Viltepso™ (viltolarsen) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Viltepso (viltolarsen) prior authorization policy effective December 17, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains existing coverage criteria for this exon 53 skipping therapy in Duchenne Muscular Dystrophy patients, requiring confirmation of DMD gene mutation, specialist prescription, baseline corticosteroid stability, ambulatory status, baseline functional assessments, and prohibition of concurrent exon 53 skipping therapies. Prior authorization remains required for all initial and renewal requests.
Medium impact
Vancomycin capsules (Revised)
Humana·Effective Jun 26, 2024
Humana Medicare Advantage has revised its vancomycin capsule prior authorization policy effective June 26, 2024. The policy maintains prior authorization requirements for vancomycin capsules (125 mg and 250 mg) when prescribed for Clostridioides difficile-associated diarrhea or Staphylococcus aureus enterocolitis. The revision clarifies that approval duration is determined by plan year or clinical review, with no changes to covered indications or approval criteria from the prior version.
Medium impact
Vancomycin (Revised)
Humana·Effective Jun 26, 2024
Humana updated its vancomycin prior authorization policy effective June 26, 2024. The policy maintains coverage for vancomycin (oral and IV formulations) limited to two specific indications: Clostridioides difficile-associated diarrhea and enterocolitis caused by Staphylococcus aureus. Prior authorization is required for all vancomycin products, with approval duration determined by plan year or clinical review.
Medium impact
Uplizna® (inebilizumab-cdon) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Uplizna (inebilizumab-cdon) prior authorization policy effective March 25, 2026, affecting Medicare and Medicaid (Kentucky and South Carolina) coverage for four indications: NMOSD, IgG4-RD, anti-AChR gMG, and anti-MuSK gMG. The policy maintains prior authorization requirements with specific clinical criteria and step therapy requirements that vary by indication and plan type (Medicare Part B, Part D, or Medicaid). Billing teams must verify which line of business applies and ensure claims include required prior authorization before submission.
Medium impact
Uceris® Tablet and Rectal Foam (budesonide) (Revised)
Humana·Effective Jan 1, 2022
This is a Medicare Advantage prior authorization policy for Uceris (budesonide) tablet and rectal foam used to treat mild-to-moderate active ulcerative colitis. The policy requires prior authorization and mandates that members must have failed or be intolerant to at least TWO aminosalicylate agents (sulfasalazine, balsalazide, mesalamine enema, or mesalamine ER capsules) before Uceris can be approved. The policy was revised on December 17, 2025, and remains effective from January 1, 2022.
Medium impact
Trintellix (vortioxetine) (Revised)
Humana·Effective Jun 24, 2026
Humana updated its Trintellix (vortioxetine) Medicare Advantage pharmacy coverage policy effective June 24, 2026. The policy maintains step therapy requirements: automatic approval is granted only to members with documented prior therapy, intolerance, or contraindication to at least one first-line antidepressant (SSRIs, SNRIs, bupropion, or mirtazapine). Billing teams must ensure prior authorization requests include evidence of failed or contraindicated first-line therapy before dispensing.
Medium impact
Tepezza® (teprotumumab) (Revised)
Humana·Effective Feb 25, 2026
Humana has revised its Tepezza (teprotumumab) pharmacy coverage policy effective February 25, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. The policy maintains prior authorization requirements with five specific clinical criteria, including diagnosis confirmation, euthyroid status, specialist prescribing requirement, lifetime infusion limits (8 infusions), and documented moderate-to-severe thyroid eye disease. No billing codes are specified in this policy document.
Medium impact
Synagis® (palivizumab) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Humana Medicare Advantage prior authorization policy for Synagis (palivizumab), effective January 1, 2022, with the most recent revision dated February 25, 2026. The policy establishes strict eligibility criteria for RSV prophylaxis in three pediatric populations: premature infants (≤35 weeks gestation, <6 months old), infants with bronchopulmonary dysplasia (≤24 months old with recent medical treatment), and infants with hemodynamically significant congenital heart disease (≤24 months old). A critical geographic requirement mandates that Florida members receive Synagis only during RSV season periods defined by the state, requiring billing teams to verify RSV season timing before approval and claim submission.
Medium impact
Statin Products (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Statin Products step therapy policy (effective 1/1/2022, revised 11/26/2025). The policy now requires members to have BOTH previous treatment with ezetimibe AND previous treatment with one of five specific statins (simvastatin, pravastatin, lovastatin, atorvastatin, or rosuvastatin) before coverage is approved for the listed statin products. This is a step therapy requirement affecting pharmacy claims for multiple statin formulations.
Medium impact
Skyrizi® (risankizumab-rzaa) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage has revised its Skyrizi (risankizumab-rzaa) prior authorization policy effective May 27, 2026. The policy maintains coverage for four indications (plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis) with specific clinical criteria requirements. Key change: Plaque psoriasis now requires documented prior therapy with or intolerance to a single conventional oral systemic treatment (e.g., methotrexate, cyclosporine), while psoriatic arthritis approval requires only diagnosis and age verification (no prior therapy requirement).
High impact
Sarclisa (isatuximab-irfc) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Humana prior authorization policy for Sarclisa (isatuximab-irfc) for multiple myeloma treatment, effective January 1, 2022, with the most recent revision dated May 27, 2026. The policy covers three treatment scenarios: third-line multiple myeloma (with pomalidomide/dexamethasone), relapsed/refractory multiple myeloma (with carfilzomib/dexamethasone), and newly diagnosed multiple myeloma ineligible for stem cell transplant (with bortezomib/lenalidomide/dexamethasone). All Sarclisa requests require prior authorization with specific clinical criteria and exclusions, with initial and renewal approvals lasting 6 months.
Medium impact
Samsca® (tolvaptan) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Samsca® (tolvaptan) prior authorization policy for Medicare Advantage members on February 25, 2026. The policy requires prior authorization for tolvaptan use in clinically significant hypervolemic or euvolemic hyponatremia, with mandatory hospital initiation per black box warning. A critical exclusion prohibits use for ADPKD outside FDA-approved REMS programs, and brand requests require documented prior therapy failure or contraindication to generic tolvaptan.
Medium impact
Ridaura® (auranofin) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Humana Medicare Advantage prior authorization policy for Ridaura (auranofin), a gold-based DMARD for rheumatoid arthritis. The policy requires members to have documented failure or intolerance to both an NSAID and a conventional DMARD before coverage is approved. The revision date of January 28, 2026 indicates this is a very recent update requiring immediate implementation.
Medium impact
Rayos® (prednisone delayed-release) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage revised its Rayos (prednisone delayed-release) prior authorization policy effective January 1, 2022, with the most recent revision on February 25, 2026. The policy maintains two key approval criteria: (1) Rayos must be used for anti-inflammatory/immunosuppressive treatment of specific conditions, and (2) members must have prior treatment history with both prednisone immediate-release AND at least one other generic corticosteroid. Prior authorization is required for all Rayos prescriptions, with approval granted for plan year durations or as determined through clinical review.
Medium impact
Pomalyst (pomalidomide) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Pomalyst (pomalidomide) prior authorization policy for Medicare Advantage members effective January 1, 2022, with a revision date of May 27, 2026. This pharmacy policy maintains strict prior authorization requirements for multiple myeloma and Kaposi sarcoma indications, with no substantive coverage criteria changes from the previous version. Billing teams should verify current policy compliance for all Pomalyst requests, as the policy requires documentation of prior therapy failures and disease progression before approval.
Medium impact
Panretin® (alitretinoin) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Panretin® (alitretinoin) prior authorization policy for Medicare Advantage effective January 1, 2022, with the most recent revision dated December 17, 2025. The policy maintains coverage for topical treatment of AIDS-related Kaposi's sarcoma cutaneous lesions only when systemic therapy is not required. Billing teams must ensure prior authorization is obtained before dispensing and verify member meets both eligibility criteria: confirmed AIDS-related Kaposi's sarcoma diagnosis and no requirement for systemic anti-KS therapy.
Medium impact
Otic Antibiotics (Revised)
Humana·Effective Feb 28, 2024
Humana revised its Otic Antibiotics step therapy policy (effective 2/28/2024) for commercial plans covering Cetraxal, Cipro HC, Ciprodex, and Otovel. The policy requires members to have documented trial, intolerance, or contraindication to TWO of three first-line otic antibiotics (ciprofloxacin ear drops, ofloxacin ear drops, or neomycin-polymyxin-HC otic solution) before approval of branded otic antibiotic combinations. This is a step therapy requirement that must be met for coverage.
Medium impact
Oral Acne Antibiotics (Revised)
Humana·Effective Apr 24, 2024
Humana revised its Oral Acne Antibiotics step therapy policy (effective April 24, 2024) to implement a two-criterion prior authorization requirement. Members must have prior treatment history with both a non-delayed release minocycline formulation AND a non-delayed release doxycycline formulation before coverage is approved for listed oral acne antibiotics. This is a step therapy policy affecting 18 covered medications.
Medium impact
Nurtec™ ODT (rimegepant) (Revised)
Humana·Effective Feb 28, 2024
This is a 1-day-old policy revision for Nurtec ODT (rimegepant) that establishes prior authorization requirements for both acute migraine treatment and migraine prevention in commercial plans. Billing teams must verify that members meet specific clinical criteria (previous treatment failure with triptans for acute use, or inadequate response to oral preventives for prevention use) before claims will be approved.
Medium impact
Nuedexta® (dextromethorphan and quinidine) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for Nuedexta (dextromethorphan/quinidine) for treating Pseudobulbar Affect (PBA). The policy requires prior authorization and confirms four approval criteria: diagnosed PBA from neurologic disease, characteristic behavioral episodes, age 18+, and provider attestation that QT prolongation risks are outweighed by treatment benefits. No significant changes from the original policy are documented—this appears to be a routine review/revision update.
Medium impact
Nourianz™ (istradefylline) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Nourianz (istradefylline) prior authorization policy for Medicare Advantage members with Parkinson's disease. The policy requires prior authorization confirming the member has documented "off" periods on carbidopa/levodopa and has failed or has contraindications to at least two adjunctive medication classes (dopamine agonists, MAO-B inhibitors, or COMT inhibitors) before Nourianz can be covered. This is a routine policy revision effective January 1, 2022, with the most recent update dated November 26, 2025.
Medium impact
Ninlaro® (ixazomib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Ninlaro® (ixazomib) prior authorization policy effective January 1, 2026. The policy maintains two approval pathways for relapsed/refractory multiple myeloma: second-line therapy requiring at least one prior therapy combined with lenalidomide/dexamethasone or cyclophosphamide/dexamethasone, and third-line+ therapy requiring at least two prior therapies combined with pomalidomide/dexamethasone. Both require prior authorization with 6-month approval duration. Members with disease progression on Ninlaro are excluded. The revision date of January 1, 2026 indicates recent updates to clinical criteria or evidence standards.
Medium impact
Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Mircera (methoxy polyethylene glycol-epoetin beta) prior authorization policy effective November 26, 2025, for Medicaid members in South Carolina and Virginia. The policy maintains existing coverage criteria for anemia of chronic kidney disease but clarifies prior authorization requirements, iron store documentation thresholds, and hemoglobin monitoring standards for both initial and renewal requests.
Medium impact
Livalo® (pitavastatin) (Revised)
Humana·Effective Jan 1, 2022
Humana has revised its Livalo® (pitavastatin) pharmacy coverage policy effective January 1, 2022, with the most recent revision dated February 25, 2026. This is a Step Therapy policy requiring members to have documented previous treatment, intolerance, or contraindication to BOTH Zypitamag and ezetimibe before Livalo coverage is approved. Billing teams must ensure prior authorization is obtained with evidence of failed or contraindicated prior therapies before processing claims.
High impact
Lifetime Dosing Limits (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has implemented lifetime dosing limit edits at point-of-sale for select FDA-limited medications. Claims exceeding FDA lifetime maximums will be stopped for clinical review. Providers can request exceptions by attesting medical necessity, which may be approved through end of plan year if clinically supported by compendia and provider rationale.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 166) | PolicyChanges.app

Viltepso™ (viltolarsen) (Revised)

Vancomycin capsules (Revised)

Vancomycin (Revised)

Uplizna® (inebilizumab-cdon) (Revised)

Uceris® Tablet and Rectal Foam (budesonide) (Revised)

Trintellix (vortioxetine) (Revised)

Tepezza® (teprotumumab) (Revised)

Synagis® (palivizumab) (Revised)

Statin Products (Revised)

Skyrizi® (risankizumab-rzaa) (Revised)

Sarclisa (isatuximab-irfc) (Revised)

Samsca® (tolvaptan) (Revised)

Ridaura® (auranofin) (Revised)

Rayos® (prednisone delayed-release) (Revised)

Pomalyst (pomalidomide) (Revised)

Panretin® (alitretinoin) (Revised)

Otic Antibiotics (Revised)

Oral Acne Antibiotics (Revised)

Nurtec™ ODT (rimegepant) (Revised)

Nuedexta® (dextromethorphan and quinidine) (Revised)

Nourianz™ (istradefylline) (Revised)

Ninlaro® (ixazomib) (Revised)

Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)

Livalo® (pitavastatin) (Revised)

Lifetime Dosing Limits (Revised)