All Insurance Policy Changes (Page 167)

Continuing from page 166. 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
Kyprolis® (carfilzomib) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Kyprolis (carfilzomib) prior authorization policy effective January 1, 2022, with the most recent revision dated May 27, 2026. The policy covers multiple myeloma and Waldenstrom's macroglobulinemia treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required for all Kyprolis use, with specific clinical criteria for approval based on disease stage, prior therapy lines, and combination therapy regimens.
Medium impact
Kuvan® (sapropterin) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Kuvan (sapropterin) prior authorization policy effective January 1, 2022, with updates as of August 27, 2025. The policy requires prior authorization for all Kuvan brand formulations, generic sapropterin, Javygtor, and Zelvysia products. Brand-name requests now require documented evidence of prior treatment failure, contraindication, or intolerance to generic sapropterin. This is a maintenance revision clarifying existing coverage criteria for PKU treatment.
Low impact
Koselugo (selumetinib) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Koselugo (selumetinib) prior authorization policy for Medicare Advantage members with neurofibromatosis type 1 (NF1) and symptomatic, inoperable plexiform neurofibromas. The policy requires prior authorization for this drug when used as monotherapy and denies approval if the member has experienced disease progression on the medication. This is a routine policy revision dated March 25, 2026.
Medium impact
Intravenous Iron Products (Revised)
Humana·Effective Mar 25, 2026
Humana updated its Intravenous Iron Products prior authorization policy (effective March 25, 2026) for Medicaid in Kentucky, South Carolina, and Virginia, and Medicare plans. The policy requires prior authorization for four IV iron products (Feraheme, Injectafer, Monoferric, ferumoxytol) with mandatory step therapy: patients must have documented prior therapy failure, contraindication, or intolerance to Infed (iron dextran) and Venofer (iron sucrose) before approval, except Medicare Part B continuation requests within 365 days. This is a billing workflow change requiring enhanced documentation review before claims submission.
Medium impact
Ingrezza® & Ingrezza Sprinkle (valbenazine) (Revised)
Humana·Effective Aug 27, 2025
Humana updated its Ingrezza (valbenazine) prior authorization policy for Medicare Advantage members effective August 27, 2025. The revised policy maintains prior auth requirements for two indications: tardive dyskinesia (with mandatory prior treatment/contraindication/intolerance to Austedo) and chorea associated with Huntington's disease (with same Austedo requirement). Key clinical additions include Black Box Warning language for depression/suicidal ideation risk in Huntington's disease patients and expanded warnings/precautions documentation.
Medium impact
Inbrija® (inhaled levodopa) (Revised)
Humana·Effective Jan 1, 2022
Humana has revised its Inbrija® (inhaled levodopa) pharmacy coverage policy for Medicare Advantage plans, effective January 1, 2022, with the most recent revision dated January 28, 2026. The policy maintains prior authorization requirements for this medication, which is used to treat breakthrough 'off' episodes in Parkinson's disease patients already on carbidopa/levodopa therapy. Billing teams must verify all three coverage criteria are met before processing claims and ensure prior authorization is obtained before dispensing.
Medium impact
Inbrija® (inhaled levodopa) (Revised)
Humana·Effective Mar 27, 2024
Humana revised its Inbrija® (inhaled levodopa) prior authorization policy effective March 27, 2024. The policy maintains existing prior authorization requirements for commercial plans covering this medication for Parkinson's disease 'off' episodes. Billing teams must verify all four approval criteria are met before claims are submitted to avoid denials.
High impact
Iclusig® (ponatinib) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Iclusig® (ponatinib) prior authorization policy effective April 22, 2026. The policy maintains strict prior authorization requirements for three indications: chronic phase CML (requires failure on 2+ TKIs or T315I mutation), accelerated/blast phase CML (requires no other kinase inhibitors available or T315I mutation), and Ph+ ALL (requires no other kinase inhibitors, T315I mutation, or use with chemotherapy). All approvals exclude members with disease progression on Iclusig. Billing teams must ensure prior authorization is obtained before dispensing for any of these indications.
Medium impact
Growth Hormone (Revised)
Humana·Effective Aug 28, 2024
Humana revised its Growth Hormone pharmacy coverage policy effective August 28, 2024, updating clinical criteria for prior authorization across 15 growth hormone products. The policy maintains coverage for pediatric indications (GH deficiency, SGA, SHOX deficiency, chronic renal insufficiency, Prader-Willi, Turner's, and Noonan syndromes) and adds adult coverage criteria. Billing teams must verify prior authorization requirements are in place for all growth hormone claims and ensure documentation meets the updated clinical criteria.
Medium impact
Gocovri® (amantadine extended release) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Gocovri (amantadine extended-release) prior authorization policy effective January 1, 2022, with updates as of November 26, 2025. The policy requires prior authorization for two indications: levodopa-induced dyskinesia in Parkinson's disease (requiring failed trial of immediate-release amantadine) and Parkinson's disease 'off' episodes (requiring prior treatment with or contraindication to at least two specific medication classes). Billing teams must verify that all Gocovri prescriptions meet these criteria before processing claims.
Medium impact
Fetzima® (levomilnacipran) (Revised)
Humana·Effective Aug 27, 2025
Humana Medicare Advantage has revised its Fetzima (levomilnacipran) prior authorization policy effective August 27, 2025. The policy now requires documentation of prior therapy, intolerance, or contraindication to specific antidepressants (SNRIs, generic bupropion, or mirtazapine) before Fetzima can be approved for Major Depressive Disorder treatment. This is a step-therapy requirement that may delay patient access and requires prior authorization submission with documented evidence of failed or contraindicated prior treatments.
Medium impact
Exondys 51 (eteplirsen) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Exondys 51 (eteplirsen) prior authorization policy effective January 1, 2022, with the most recent revision dated December 17, 2025. This policy establishes strict prior authorization requirements for this rare disease therapy used to treat Duchenne Muscular Dystrophy (DMD), requiring confirmation of exon 51-amenable mutations, specialist prescription, baseline ambulatory function testing, and corticosteroid stability before initial approval. Renewal requires documented improvement or maintenance of ambulatory function compared to predicted disease progression.
Medium impact
Empliciti (elotuzumab) (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Empliciti (elotuzumab) prior authorization policy effective February 25, 2026, clarifying coverage criteria for multiple myeloma treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires prior authorization and specifies that coverage is limited to patients with disease progression after 1-3 prior lines of therapy (with lenalidomide/dexamethasone or bortezomib/dexamethasone combinations) or at least 2 prior therapies including lenalidomide and proteasome inhibitors (with pomalidomide/dexamethasone). Billing teams must ensure all Empliciti requests meet these updated clinical criteria before claim submission.
Medium impact
EMSAM® (selegiline transdermal system) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for EMSAM® (selegiline transdermal system) for treating major depressive disorder. The policy requires prior authorization and mandates that patients have failed or been intolerant to generic SSRIs, SNRIs, bupropion, or mirtazapine before EMSAM® can be approved. The revision date of February 25, 2026 indicates recent updates to this existing policy.
Medium impact
Dihydroergotamine Products (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Dihydroergotamine Products prior authorization policy (effective 1/1/2022, revised 9/24/2025). The policy requires prior authorization for dihydroergotamine nasal spray and injection for acute migraine treatment. Prior to approval, members must demonstrate previous treatment, intolerance, or contraindication to at least TWO of four specified first-line agents (naproxen, naratriptan, rizatriptan, or sumatriptan). Approvals are granted for the plan year duration with annual renewal options.
Medium impact
Desmopressin Nasal Spray (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage updated its Desmopressin Nasal Spray prior authorization policy (revision dated April 24, 2024). The policy requires prior authorization for desmopressin nasal spray with one key criterion: members must have had previous treatment or intolerance with generic desmopressin tablets. Approval is granted for the initial plan year duration. This is a refreshed policy document with the same effective date (January 1, 2022) but recent clinical review.
Medium impact
Defitelio® (defibrotide sodium) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Defitelio (defibrotide sodium) pharmacy coverage policy effective January 1, 2022, with the most recent revision dated March 25, 2026. This is a prior authorization policy for treating veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) following hematopoietic stem-cell transplantation. The policy requires prior authorization for all uses and explicitly prohibits concomitant use with systemic anticoagulants or fibrinolytic therapy.
Medium impact
Dayvigo™ (lemborexant) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Dayvigo (lemborexant) prior authorization policy, effective January 1, 2022, with the most recent revision dated December 17, 2025. The policy requires prior authorization for this insomnia medication and mandates that members have documented failed treatment, contraindication, or intolerance to Belsomra (suvorexant) or trazodone before approval. The policy explicitly excludes members with narcolepsy from coverage.
Medium impact
Darzalex® (daratumumab) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Darzalex (daratumumab) prior authorization policy effective January 28, 2026, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy clarifies coverage criteria for newly diagnosed and relapsed/progressive multiple myeloma, specifying required combination therapies and prior treatment thresholds. No substantive clinical coverage changes are apparent—this is a policy refinement/republication.
High impact
Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Darzalex Faspro (daratumumab and hyaluronidase-fihj) prior authorization policy effective January 1, 2022, with the most recent revision dated March 25, 2026. The policy covers three indications: multiple myeloma (newly diagnosed and relapsed/progressive disease), light chain amyloidosis (newly diagnosed), and high-risk smoldering multiple myeloma. All requests require prior authorization and must meet specific combination therapy or monotherapy criteria with documented clinical justification.
Medium impact
Bowel Prep Agents (Revised)
Humana·Effective May 22, 2024
Humana has revised its Bowel Prep Agents pharmacy coverage policy (effective January 1, 2022, revised May 22, 2024) to implement step therapy requiring members to have a documented trial, intolerance, or contraindication to Clenpiq before coverage of alternative bowel prep agents (MoviPrep, OsmoPrep, Plenvu, Sutab, Suprep, Suflave, and generic equivalents). This is a step therapy requirement that affects all bowel prep prescriptions for covered members.
Medium impact
Bosulif® (bosutinib) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage updated its Bosulif (bosutinib) prior authorization policy effective January 1, 2022, with the most recent revision on April 22, 2026. This policy requires prior authorization for bosutinib coverage in Medicare Advantage members with Philadelphia chromosome-positive chronic myelogenous leukemia (CML), with specific approval criteria and exclusions based on disease phase, prior treatment, and specific mutations. The billing team must ensure all Bosulif claims include prior authorization documentation and verify member eligibility against the stated clinical criteria before claim submission.
Medium impact
Bosentan Products (Revised)
Humana·Effective Jan 1, 2022
This is a revised Humana Medicare Advantage prior authorization policy for bosentan products (Tracleer) used to treat pulmonary arterial hypertension (PAH). The policy requires prior authorization for all bosentan formulations and mandates that patients have confirmed PAH diagnosis via right heart catheterization. For brand Tracleer and generic bosentan oral suspension, prior treatment, intolerance, or contraindication with generic bosentan tablet must be documented. The policy emphasizes critical safety monitoring including liver function tests, hemoglobin levels, and monthly pregnancy testing due to black box warnings.
High impact
Bortezomib products (Velcade and Bortezomib for injection) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its prior authorization policy for bortezomib products (Velcade and generic bortezomib for injection) effective January 1, 2022, with the most recent revision dated February 25, 2026. The policy covers three indications: mantle cell lymphoma, multiple myeloma, and Waldenström's macroglobulinemia, all requiring prior authorization. A key exclusion applies across all three indications: members who have experienced disease progression while on a bortezomib-containing regimen may not receive approval. This is a recent update (1 day old) affecting Medicaid programs in Kentucky and South Carolina, plus Medicare.
Medium impact
BiDil® (isosorbide dinitrate/hydralazine) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its BiDil® (isosorbide dinitrate/hydralazine) prior authorization policy effective January 1, 2022, with the most recent revision dated April 22, 2026. The policy requires prior authorization for BiDil tablet coverage in Medicare Advantage members with NYHA Class II-IV heart failure who have prior therapy with isosorbide dinitrate combined with hydralazine. Billing teams must ensure all BiDil claims include documented prior authorization and meet the two clinical criteria before submission.

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Archive by year

2023 2024 2025 2026

Kyprolis® (carfilzomib) (Revised)

Kuvan® (sapropterin) (Revised)

Koselugo (selumetinib) (Revised)

Intravenous Iron Products (Revised)

Ingrezza® & Ingrezza Sprinkle (valbenazine) (Revised)

Inbrija® (inhaled levodopa) (Revised)

Inbrija® (inhaled levodopa) (Revised)

Iclusig® (ponatinib) (Revised)

Growth Hormone (Revised)

Gocovri® (amantadine extended release) (Revised)

Fetzima® (levomilnacipran) (Revised)

Exondys 51 (eteplirsen) (Revised)

Empliciti (elotuzumab) (Revised)

EMSAM® (selegiline transdermal system) (Revised)

Dihydroergotamine Products (Revised)

Desmopressin Nasal Spray (Revised)

Defitelio® (defibrotide sodium) (Revised)

Dayvigo™ (lemborexant) (Revised)

Darzalex® (daratumumab) (Revised)

Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Revised)

Bowel Prep Agents (Revised)

Bosulif® (bosutinib) (Revised)

Bosentan Products (Revised)

Bortezomib products (Velcade and Bortezomib for injection) (Revised)

BiDil® (isosorbide dinitrate/hydralazine) (Revised)