All Insurance Policy Changes (Page 169)

Continuing from page 168. 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
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)
Humana·Effective May 27, 2026
Humana revised its Pluvicto (lutetium Lu 177 vipivotide tetraxetan) pharmacy coverage policy effective May 27, 2026, for Medicare and four Medicaid state programs (Florida, Kentucky, South Carolina, Virginia). The policy maintains prior authorization requirements for this radioligand therapeutic agent used in metastatic castration-resistant prostate cancer, with specific criteria around PSMA-positive disease confirmation, prior ARPI therapy failure, and taxane chemotherapy status. Billing teams must ensure all Pluvicto requests comply with the four approval criteria and document the required clinical conditions to avoid claim denials.
Medium impact
Byooviz® (ranibizumab-nuna) (Revised)
Humana·Effective Feb 25, 2026
Humana updated its Byooviz (ranibizumab-nuna) prior authorization policy effective February 25, 2026, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy requires prior authorization for three ophthalmic conditions with a key exception: Florida Medicaid requests are exempt from bevacizumab step-therapy requirements, and Medicare Part B continuation therapy within 365 days bypasses step therapy.
Medium impact
Ztalmy® (ganaxolone) (Revised)
Humana·Effective Jul 27, 2022
Humana updated its Ztalmy® (ganaxolone) pharmacy coverage policy for Medicare Advantage members with a revision date of March 25, 2026. The policy establishes prior authorization requirements for Ztalmy oral suspension (50 mg/ml) for treating seizures associated with CDKL5 Deficiency Disorder in patients age 2 and older. The single approval criterion requires documentation of a confirmed CDKL5 Deficiency Disorder (CDD) diagnosis, with coverage approved for the full plan year on initial and renewal requests.
Medium impact
Vijoice® (alpelisib) (Revised)
Humana·Effective Jul 27, 2022
Humana Medicare Advantage has revised its Vijoice® (alpelisib) prior authorization policy effective February 25, 2026. The policy covers this PI3K inhibitor for adult and pediatric patients (age 2+) with severe manifestations of PIK3CA-Related Overgrowth Spectrum (PROS) requiring systemic therapy, contingent on meeting three clinical criteria: confirmed PIK3CA gene mutation, PROS diagnosis, and physician-documented severe/life-threatening disease manifestations. All three Vijoice formulations (50mg, 125mg, 250mg tablets and 50mg granule packets) require prior authorization before dispensing.
Low impact
Korsuva™ (difelikefalin) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage has revised its prior authorization policy for Korsuva™ (difelikefalin) effective May 27, 2026. The policy maintains existing coverage criteria requiring CKD-associated pruritus diagnosis and consistent hemodialysis (3+ times weekly for 3 months), with initial approval for 6 months and renewal approvals for plan year durations. This is a routine policy revision with no changes to approval criteria or billing requirements.
Medium impact
Enjaymo™ (sutimlimab-jome) (Revised)
Humana·Effective Jul 23, 2025
Humana Medicaid Ohio has updated its prior authorization policy for Enjaymo (sutimlimab-jome) effective July 23, 2025. This is a revised policy (originally effective July 27, 2022) with updated clinical criteria for initial approval and renewal. The billing team must ensure all Enjaymo claims for Ohio Medicaid members include prior authorization documentation demonstrating patient meets strict diagnostic, lab, vaccination, and medication interaction criteria before dispensing.
High impact
Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage is updating its prior authorization policy for abuse-deterrent oxycodone tablets (RoxyBond, Oxaydo, and generics), effective January 1, 2026. The policy requires prior authorization for all abuse-deterrent oxycodone oral tablets and mandates that patients have failed or been intolerant to at least two alternative immediate-release opioids before approval. This is a revision to the original July 27, 2022 policy.
Medium impact
Reyvow™ (lasmiditan) (Revised)
Humana·Effective Mar 27, 2024
Humana updated its Reyvow™ (lasmiditan) prior authorization policy on March 27, 2024. The policy requires prior authorization for acute migraine treatment and mandates documented previous treatment failure or contraindication to Nurtec or Ubrelvy before approval. Key safety restrictions include limiting use to no more than 4 migraines per 30-day period and requiring 8-hour driving/machinery restrictions post-dose.
Medium impact
Calcitonin gene-related peptide (CGRP) inhibitors (Revised)
Humana·Effective Mar 27, 2024
Humana revised its CGRP inhibitor prior authorization policy effective March 27, 2024. For migraine prevention with Ajovy and Emgality (120 mg/mL), the policy now requires prior treatment failure with Aimovig OR Nurtec ODT OR Qulipta (with a Medicaid-South Carolina exception). This expands the previous step-therapy requirements and clarifies which agents satisfy initial treatment failure criteria before approving second-line CGRP inhibitors.
Medium impact
Meloxicam oral suspension (Revised)
Humana·Effective Jul 24, 2024
Humana updated its meloxicam oral suspension prior authorization policy (revised July 24, 2024) for commercial plans. The policy requires prior authorization for meloxicam oral suspension across three indications: osteoarthritis, rheumatoid arthritis, and juvenile rheumatoid arthritis. Coverage requires documented prior therapy failure, contraindication, or intolerance with both meloxicam tablets AND ibuprofen oral suspension, plus exclusion screening for NSAID allergies and recent CABG surgery.
Low impact
Hyftor™ (sirolimus topical gel) (Revised)
Humana·Effective Sep 28, 2025
Humana updated its Hyftor™ (sirolimus topical gel) prior authorization policy effective September 28, 2022, with a recent revision dated September 24, 2025. This is a maintenance update to the existing policy requiring prior authorization for Hyftor use in Medicare Advantage members with tuberous sclerosis complex (TSC) who have ≥3 facial angiofibromas and are not on systemic mTOR inhibitors. No billing codes are specified in this policy document.
Medium impact
Zonisade™ (zonisamide) (Revised)
Humana·Effective Jun 24, 2026
Humana Medicare Advantage updated its Zonisade (zonisamide) oral suspension prior authorization policy effective June 24, 2026. The policy now requires prior authorization for this adjunctive seizure medication and mandates that members must have failed or be unable to use zonisamide capsules AND at least one other antiepileptic drug before approval. This is a revision to the original October 26, 2022 policy.
Medium impact
Nexiclon™ XR (clonidine ER) tablet (Revised)
Humana·Effective Oct 26, 2022
Humana updated its Nexiclon™ XR (clonidine ER) pharmacy coverage policy for Medicare Advantage members, effective October 26, 2022, with a revision dated September 24, 2025. This is a prior authorization (PA) policy requiring members to have a hypertension diagnosis AND prior treatment failure, intolerance, or contraindication to immediate-release clonidine before coverage is approved. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility against both criteria.
Medium impact
Camzyos™ (mavacamten) (Revised)
Humana·Effective Oct 26, 2025
Humana Medicare Advantage updated its prior authorization policy for Camzyos (mavacamten) on October 22, 2025. The policy establishes strict approval criteria requiring diagnosis confirmation, NYHA Class II-III symptoms, LVEF >55% at initiation, and prior treatment failure/intolerance to beta-blockers or non-dihydropyridine calcium channel blockers. Initial approval is for 6 months with renewal requiring LVEF >50%, clinical improvement documentation, and provider attestation against concurrent septal reduction therapy.
Medium impact
Spevigo® (spesolimab-sbzo) intravenous solution (Revised)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage has revised its prior authorization policy for Spevigo® (spesolimab-sbzo) for treating Generalized Pustular Psoriasis flares, effective February 25, 2026. The policy requires prior authorization and mandates specific clinical criteria including specialist oversight (dermatology/rheumatology), documented GPP flare severity scores, and prior treatment failure or contraindication to oral systemic therapies. Billing teams must ensure all Spevigo requests meet these three criteria before claims processing.
Medium impact
Methocarbamol Containing Products (Revised)
Humana·Effective Apr 2, 2026
Humana Medicare Advantage has revised its prior authorization policy for methocarbamol-containing products (methocarbamol tablets, Tanlor, Atmeksi) effective April 2, 2026. The policy requires prior authorization for these muscle relaxants and mandates that members must have had a trial with, intolerance, or contraindication to both methocarbamol 500mg AND 750mg tablets before approval for higher-strength formulations. Billing teams must implement prior authorization requirements in their systems and ensure providers document trial history before prescribing.
Medium impact
Xenpozyme™ (olipudase alfa) intravenous solution (Revised)
Humana·Effective Nov 30, 2022
This is a revised Humana prior authorization policy for Xenpozyme (olipudase alfa) for treating non-CNS manifestations of Acid Sphingomyelinase Deficiency (ASMD). The policy was updated May 27, 2026 and applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required for all claims, with approval granted for one plan year at initial authorization and renewal.
Medium impact
Pedmark® (sodium thiosulfate injection) (Revised)
Humana·Effective Mar 25, 2026
Humana Medicaid Ohio revised its Pedmark (sodium thiosulfate injection) coverage policy effective March 25, 2026. This is a prior authorization requirement for pediatric patients (1 month to <18 years) receiving cisplatin-based therapy for localized, non-metastatic solid tumors to reduce ototoxicity risk. The policy specifies weight-based dosing, timing requirements (6 hours after cisplatin completion, minimum 10 hours before next infusion), and a critical limitation: cisplatin infusions longer than 6 hours may negate protective benefit.
Medium impact
Medical Necessity Determinations (Revised)
Humana·Effective Nov 26, 2025
Humana has updated its Medical Necessity Determinations policy for Ohio Medicaid pharmacy coverage, effective November 26, 2025. The policy clarifies the hierarchy for reviewing pharmacy requests: state/federal regulatory criteria first, then Pharmacy Benefit Manager (Gainwell) clinical criteria, followed by Humana clinical criteria, and approved compendia. Approval duration is set to the initial plan year for new requests and renewal plan year for renewals. This is a guidance document that standardizes how medical necessity reviews are conducted for pharmacy products.
Medium impact
Pheburane® and Olpruva™ (sodium phenylbutyrate) (Revised)
Humana·Effective Dec 28, 2022
This is a revised Medicare Advantage pharmacy prior authorization policy for Pheburane® and Olpruva™ (sodium phenylbutyrate) products used to treat urea cycle disorders. The policy requires prior authorization and mandates that members must have tried or be unable to use generic sodium phenylbutyrate before these brand products are covered. Coverage is limited to plan year duration for both initial and renewal periods.
Medium impact
Furoscix® (furosemide) (Revised)
Humana·Effective Dec 28, 2022
Humana Medicare Advantage has revised its Furoscix (furosemide) subcutaneous injection prior authorization policy, effective December 28, 2022, with the most recent revision dated December 17, 2025. The policy requires prior authorization for Furoscix and mandates that patients meet three criteria: diagnosis of heart failure or chronic kidney disease (including nephrotic syndrome), documented edema, and previous treatment with oral loop diuretics. Billing teams must ensure all Furoscix claims include prior authorization and verify patients meet all eligibility criteria before processing.
Medium impact
Zydelig® (idelalisib) (Revised)
Humana·Effective Jun 25, 2025
Humana Medicare Advantage updated its Zydelig (idelalisib) prior authorization policy effective June 25, 2025. The key change is a new exclusion criterion: members who have experienced disease progression while on or following ANY PI3K inhibitor (including idelalisib and copanlisib) are now ineligible for coverage. This tightens access to the drug for relapsed/refractory CLL patients with prior PI3K inhibitor exposure.
Medium impact
Yescarta™ (axicabtagene ciloleucel) (Revised)
Humana·Effective May 1, 2026
Humana Louisiana Medicaid revised its Yescarta (axicabtagene ciloleucel) prior authorization policy effective May 1, 2026, maintaining coverage for relapsed/refractory large B-cell lymphoma (2L and 3L) and follicular lymphoma with specific clinical criteria. The policy requires prior authorization, limits approval to 60 days per dose with a maximum of one lifetime dose, and maintains the same exclusion criteria including prior CD-19 targeted therapy and certain infections. Billing teams must ensure all Yescarta requests include mandatory prior authorization through the Corporate Transplant Department.
Medium impact
Xofigo® (radium Ra 223 dichloride) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Xofigo (radium Ra 223 dichloride) prior authorization policy effective April 22, 2026, for Medicaid members in Florida, Kentucky, and South Carolina. The policy maintains strict eligibility criteria requiring metastatic castration-resistant prostate cancer with symptomatic bone metastases, no visceral disease, and concurrent bone modifying agent use. Prior authorization remains required with 6-month approval/renewal cycles.
Medium impact
Winlevi® (clascoterone) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage has revised its prior authorization policy for Winlevi® (clascoterone) cream, effective January 1, 2023, with the most recent revision dated February 25, 2026. The policy requires prior authorization for topical clascoterone treatment of acne vulgaris in patients 12+ years old, with mandatory prior failure or contraindication/intolerance to at least two specified topical acne medications. Billing teams must ensure all Winlevi prescriptions include prior authorization before claims are processed.

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Archive by year

2023 2024 2025 2026

Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)

Byooviz® (ranibizumab-nuna) (Revised)

Ztalmy® (ganaxolone) (Revised)

Vijoice® (alpelisib) (Revised)

Korsuva™ (difelikefalin) (Revised)

Enjaymo™ (sutimlimab-jome) (Revised)

Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)

Reyvow™ (lasmiditan) (Revised)

Calcitonin gene-related peptide (CGRP) inhibitors (Revised)

Meloxicam oral suspension (Revised)

Hyftor™ (sirolimus topical gel) (Revised)

Zonisade™ (zonisamide) (Revised)

Nexiclon™ XR (clonidine ER) tablet (Revised)

Camzyos™ (mavacamten) (Revised)

Spevigo® (spesolimab-sbzo) intravenous solution (Revised)

Methocarbamol Containing Products (Revised)

Xenpozyme™ (olipudase alfa) intravenous solution (Revised)

Pedmark® (sodium thiosulfate injection) (Revised)

Medical Necessity Determinations (Revised)

Pheburane® and Olpruva™ (sodium phenylbutyrate) (Revised)

Furoscix® (furosemide) (Revised)

Zydelig® (idelalisib) (Revised)

Yescarta™ (axicabtagene ciloleucel) (Revised)

Xofigo® (radium Ra 223 dichloride) (Revised)

Winlevi® (clascoterone) (Revised)