All Insurance Policy Changes (Page 168)

Continuing from page 167. 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
Balversa (erdafitinib) (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Medicare Advantage prior authorization policy for Balversa (erdafitinib) effective February 25, 2026. The policy maintains three strict approval criteria: locally advanced/metastatic urothelial carcinoma with documented FGFR3 genetic alterations, and use as subsequent therapy after at least one prior systemic therapy line including a PD-1/PD-L1 inhibitor. Initial and renewal approvals are limited to 6-month periods, and billing teams must verify genetic testing documentation is in the medical record before claim submission.
Medium impact
Austedo® & Austedo® XR (deutetrabenazine) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Medicare Advantage prior authorization policy for Austedo® & Austedo® XR (deutetrabenazine) on June 25, 2025. The policy maintains prior authorization requirements for tardive dyskinesia and chorea associated with Huntington's disease, with approval duration for both initial and renewal covering the plan year. Key clinical criteria remain unchanged, including documented failure of dopamine-blocking agent reduction for tardive dyskinesia and confirmed Huntington's disease diagnosis for chorea treatment.
High impact
Anticholinergic Polypharmacy Agents (Revised)
Humana·Effective May 13, 2026
Humana has updated its Anticholinergic Polypharmacy guidance (revised May 13, 2026) to implement a safety edit that restricts concurrent use of multiple anticholinergic medications for members aged 65+, unless the provider attests that benefits outweigh risks per American Geriatrics Society Beers Criteria and provides patient education. Members in hospice are exempt from this restriction. This affects pharmacy claims across Medicare and multiple state Medicaid programs.
Medium impact
Actinic Keratosis Agents (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage revised its Actinic Keratosis Agents prior authorization policy (effective 1/1/2022, revised 11/26/2025). The policy covers diclofenac topical gel and Klisyri (tirbanibulin) ointment for actinic keratosis treatment, requiring prior authorization. Billing teams must ensure all claims for these agents include documentation that the member has tried, experienced intolerance to, or has contraindications to generic imiquimod 5% cream or topical fluorouracil before requesting approval.
Medium impact
Livtencity (maribavir) tablet (Revised)
Humana·Effective Jan 19, 2022
This is a revised Humana Medicare Advantage prior authorization policy for Livtencity (maribavir) effective January 19, 2022, with the most recent revision dated March 25, 2026. The policy requires prior authorization for this CMV treatment drug and specifies two strict approval criteria: patient must have post-transplant CMV infection AND be refractory to ganciclovir, valganciclovir, cidofovir, or foscarnet. Critical warnings include drug interaction risks with immunosuppressants (tacrolimus, cyclosporine, sirolimus, everolimus) requiring frequent monitoring.
Medium impact
Besremi (ropeginterferon alfa-2b-njft) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Besremi (ropeginterferon alfa-2b-njft) prior authorization policy for Medicare Advantage members with Polycythemia Vera, effective November 26, 2025. The policy requires prior authorization for all Besremi subcutaneous syringes and maintains six specific exclusion criteria (hepatic decompensation, severe psychiatric disorders, immunosuppressed transplant recipients, hypersensitivity, active autoimmune disease, and disease progression on therapy). No changes to billing codes or coverage criteria are noted compared to the original effective date; this is a routine policy revision.
Medium impact
Xipere® (triamcinolone acetonide) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Xipere (triamcinolone acetonide) prior authorization policy effective October 22, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy requires prior authorization for this suprachoroidal injectable suspension used to treat macular edema associated with uveitis. The single clinical criterion is confirmation of macular edema associated with uveitis diagnosis. Approval duration is determined by plan year or clinical review for both initial and renewal requests.
Medium impact
Voxzogo™ (vosoritide) (Revised)
Humana·Effective Feb 23, 2022
Humana Medicare Advantage updated its Voxzogo (vosoritide) prior authorization policy on June 24, 2026. The policy requires prior authorization for this CNP analog injection used to treat pediatric achondroplasia, with three specific approval criteria: genetically confirmed diagnosis, open epiphyses confirmed by imaging, and specialist prescribing/consultation. Approval is granted in plan year durations or through clinical review.
Medium impact
Tarpeyo™ (budesonide) delayed-release capsules (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage has revised its prior authorization policy for Tarpeyo (budesonide) delayed-release capsules for primary IgA nephropathy treatment, effective March 25, 2026. The policy requires two approval criteria: confirmed IgAN diagnosis by biopsy and use to reduce kidney function loss in patients at risk for disease progression. Billing teams must ensure all Tarpeyo claims include prior authorization before submission to avoid denials.
Medium impact
Fyarro (sirolimus protein-bound particles for injectable suspension) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its prior authorization policy for Fyarro (sirolimus protein-bound particles for injectable suspension) effective June 24, 2026. The policy covers this mTOR inhibitor for adult patients with locally advanced unresectable or metastatic perivascular epithelioid cell tumor (PEComa) as monotherapy. Billing teams must ensure prior authorization is obtained before claim submission for Medicare and Medicaid members in Florida, Kentucky, and South Carolina.
Medium impact
Dartisla ODT (glycopyrrolate) (Revised)
Humana·Effective Oct 22, 2025
Humana has revised its Dartisla ODT (glycopyrrolate) coverage policy, effective October 22, 2025. This is a step therapy policy requiring members to have previous treatment or intolerance to glycopyrrolate tablet before Dartisla ODT (the orally disintegrating formulation) will be covered for adjunct peptic ulcer treatment. This is a pharmacy policy affecting prior authorization requirements for this specific medication.
Medium impact
Tavneos™ (avacopan) (Revised)
Humana·Effective Dec 17, 2025
Humana updated its Tavneos (avacopan) prior authorization policy for Medicare Advantage members on December 17, 2025. The policy maintains strict coverage criteria requiring diagnosis of GPA or MPA, positive ANCA testing, severe disease manifestations, specialist prescribing, and combination therapy. For renewals, members must demonstrate positive clinical response with disease stabilization or absence of progression.
Medium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
Humana·Effective Aug 27, 2025
Humana revised its prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) effective August 27, 2025. The policy clarifies coverage criteria for generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP), requiring prior authorization and specific clinical criteria including specialist oversight, documented diagnosis confirmation, and prior treatment history for Medicaid and Medicare Ohio members.
Medium impact
Kimmtrak (tebentafusp-tebn) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Kimmtrak (tebentafusp-tebn) prior authorization policy effective October 22, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy requires prior authorization for this rare cancer immunotherapy targeting HLA-A*02:01-positive unresectable or metastatic uveal melanoma patients. Key criteria include HLA-A*02:01 genetic confirmation and monotherapy use; patients with prior disease progression on Kimmtrak are excluded from coverage.
Medium impact
Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Opdualag (nivolumab and relatlimab-rmbw) prior authorization policy effective March 25, 2026. The policy applies to Medicare, Medicaid (Florida, Kentucky, South Carolina) and requires prior authorization for this immune checkpoint inhibitor combination therapy in patients 12+ years old with unresectable or metastatic melanoma. Key exclusions include prior disease progression on anti-PD-1/PD-L1 combination therapy and concurrent use with BRAF/MEK inhibitors. Initial and renewal approvals are valid for 6 months or as determined through clinical review.
Medium impact
Soaanz® (torsemide) (Revised)
Humana·Effective Jan 28, 2026
Humana has revised its Soaanz® (torsemide) pharmacy coverage policy effective January 28, 2026. This is a step therapy policy for Medicare Advantage members requiring prior authorization. Members must have prior treatment with at least two of the following loop diuretics before Soaanz approval: furosemide, bumetanide, or torsemide. The policy applies to treatment of edema associated with heart failure or renal disease.
Medium impact
Ryplazim (plasminogen, human-tvmh) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its prior authorization policy for Ryplazim (plasminogen, human-tvmh) effective December 17, 2025, for Medicare and select state Medicaid programs (FL, KY, SC, VA). This is a rare disease therapy requiring prior authorization with four specific clinical criteria: hematologist prescription, confirmed Type 1 plasminogen deficiency diagnosis, baseline plasminogen activity ≤45%, and documented history of associated lesions/symptoms. Billing teams must ensure all four criteria are met before claims are submitted and prior authorization is obtained.
Medium impact
Recorlev® (levoketoconazole) Tablet (Revised)
Humana·Effective Jan 22, 2025
Humana Medicare Advantage has revised its prior authorization policy for Recorlev® (levoketoconazole) effective January 22, 2025. The policy requires prior authorization for this orphan drug used to treat Cushing's syndrome, with three mandatory approval criteria: confirmed Cushing's syndrome diagnosis, patient ineligibility for or failure of surgical intervention, and documented prior treatment failure or contraindication/intolerance to oral ketoconazole. Billing teams must ensure all Recorlev claims include prior authorization and supporting clinical documentation before submission to avoid denials.
High impact
Pemetrexed Products (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Pemetrexed Products prior authorization policy effective September 24, 2025, affecting coverage for pemetrexed-based chemotherapy across multiple pemetrexed formulations (Alimta, Pemfexy, Pemrydi RTU, Axtle) for malignant pleural mesothelioma and non-squamous non-small cell lung cancer. The policy maintains prior authorization requirements and renal function exclusions (CrCl < 45 ml/min) but clarifies approved treatment combinations and adds new first-line pembrolizumab-combination therapy criteria for NSCLC patients without EGFR/ALK mutations.
Medium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·Effective May 1, 2026
Humana Kentucky Medicaid revised its prior authorization policy for Carvykti (ciltacabtagene autoleucel) effective May 1, 2026. The policy establishes strict approval criteria requiring diagnosis of relapsed/refractory multiple myeloma with prior treatment including immunomodulatory agents, proteasome inhibitors, and anti-CD38 monoclonal antibodies. Coverage is limited to one lifetime dose approved for 60 days, with three key exclusions: active hepatitis B/C, prior allogeneic transplant, and prior CAR-T therapy. All requests must be routed to the Corporate Transplant Department.
Medium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·Effective Feb 19, 2026
Humana Medicare Advantage has revised its Carvykti (ciltacabtagene autoleucel) coverage policy effective February 19, 2026. This is a CAR-T cell immunotherapy for relapsed/refractory multiple myeloma requiring prior authorization. The policy mandates five specific clinical criteria be met before approval, with a maximum of one lifetime dose approved for a 60-day duration. All requests must be routed to Humana's Corporate Transplant Department.
Medium impact
Aduhelm® (aducanumab-avwa) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage has revised its Aduhelm (aducanumab-avwa) pharmacy coverage policy, effective November 26, 2025. The policy now requires that ALL Aduhelm requests—both initial and renewal—mandate enrollment in an FDA-approved randomized controlled trial or NIH-supported clinical trial as the sole approval criterion. This is a restrictive coverage policy that essentially limits Aduhelm access to trial participants only.
Medium impact
Vabysmo® (faricimab-svoa) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Vabysmo (faricimab-svoa) prior authorization policy effective March 25, 2026, covering three retinal indications across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The policy maintains step therapy requirements (bevacizumab contraindication/intolerance or failed prior therapy) for all three indications, with a critical exception: Florida Medicaid requests are exempt from the bevacizumab step therapy requirement (^Does not apply to Florida Medicaid requests). This is a revised policy that supersedes previous guidance.
Medium impact
Cibinqo® (abrocitinib) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Cibinqo (abrocitinib) prior authorization policy effective December 17, 2025. This is a JAK inhibitor for moderate-to-severe atopic dermatitis in patients 12+ years old. The policy requires prior authorization and mandates documented failure/contraindication/intolerance with both Dupixent AND Rinvoq before approval. Claims will be denied if these prerequisites are not met.
High impact
Tezspire™ (tezepelumab-ekko) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage has revised its Tezspire (tezepelumab-ekko) prior authorization policy effective November 26, 2025. The policy maintains coverage for severe asthma and chronic rhinosinusitis with nasal polyposis but requires strict prior authorization with specific clinical criteria, including documented exacerbations, maximum tolerated ICS/LABA therapy, and prohibition of concurrent use with other biologic agents (anti-IgE, anti-IL4, anti-IL5). Billing teams must verify prior authorization is obtained before dispensing and ensure claims meet all documented criteria.

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Archive by year

2023 2024 2025 2026

Balversa (erdafitinib) (Revised)

Austedo® & Austedo® XR (deutetrabenazine) (Revised)

Anticholinergic Polypharmacy Agents (Revised)

Actinic Keratosis Agents (Revised)

Livtencity (maribavir) tablet (Revised)

Besremi (ropeginterferon alfa-2b-njft) (Revised)

Xipere® (triamcinolone acetonide) (Revised)

Voxzogo™ (vosoritide) (Revised)

Tarpeyo™ (budesonide) delayed-release capsules (Revised)

Fyarro (sirolimus protein-bound particles for injectable suspension) (Revised)

Dartisla ODT (glycopyrrolate) (Revised)

Tavneos™ (avacopan) (Revised)

Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)

Kimmtrak (tebentafusp-tebn) (Revised)

Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)

Soaanz® (torsemide) (Revised)

Ryplazim (plasminogen, human-tvmh) (Revised)

Recorlev® (levoketoconazole) Tablet (Revised)

Pemetrexed Products (Revised)

Carvykti™ (ciltacabtagene autoleucel) (Revised)

Carvykti™ (ciltacabtagene autoleucel) (Revised)

Aduhelm® (aducanumab-avwa) (Revised)

Vabysmo® (faricimab-svoa) (Revised)

Cibinqo® (abrocitinib) (Revised)

Tezspire™ (tezepelumab-ekko) (Revised)