All Insurance Policy Changes (Page 170)

Continuing from page 169. 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
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.
Medium impact
Vabysmo® (faricimab-svoa) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicaid Louisiana revised its prior authorization policy for Vabysmo (faricimab-svoa) effective January 1, 2023, with a revision date of March 25, 2026. The policy requires prior authorization for three retinal conditions (wet AMD, DME, and RVO-related macular edema), with approval contingent on documented contraindication/intolerance to bevacizumab OR failure to demonstrate positive clinical response to prior bevacizumab therapy. Billing teams must verify all three criteria are met and documented before claim submission to avoid denials.
Medium impact
Tykerb (lapatinib) (Revised)
Humana·Effective Jan 1, 2023
Humana revised its Tykerb (lapatinib) prior authorization policy effective January 1, 2023, with a revision date of November 26, 2025. The policy maintains prior authorization requirements for brand Tykerb (requiring documented intolerance/contraindication to generic lapatinib) and defines specific clinical criteria for HER2-positive breast cancer treatment. Key criteria include advanced/metastatic HER2-positive disease with prior anthracycline and taxane therapy, or first-line use with aromatase inhibitors for hormone receptor-positive disease. Members with disease progression on Tykerb are excluded from coverage.
Medium impact
Topical Tazarotene Products (Arazlo®, Fabior®) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Medicare Advantage prior authorization policy for topical tazarotene products (Arazlo lotion and Fabior foam) used to treat acne vulgaris. The policy requires members to have a documented diagnosis of acne vulgaris AND prior treatment with, intolerance, or contraindication to tretinoin (non-micro) or adapalene 0.1% gel before coverage is approved. Cosmetic uses are excluded.
Medium impact
Topical Onychomycotic Agents (Revised)
Humana·Effective Jan 1, 2023
This is a refreshed Medicare Advantage prior authorization policy for topical onychomycotic agents (Jublia, Kerydin, tavaborole) effective January 1, 2023, with a revision date of February 25, 2026. The policy requires prior authorization for these topical antifungal treatments and mandates that members have a diagnosis of toenail onychomycosis caused by specific Trichophyton species AND documented failure or contraindication to oral antifungal therapy (terbinafine plus at least one of: itraconazole, ciclopirox, or griseofulvin). No new changes to requirements are evident, but billing teams must ensure compliance with these two strict criteria for all pharmacy claims.
Medium impact
Tecvayli (teclistamab-cqyv) (Revised)
Humana·Effective Jan 1, 2023
This is a REVISED Tecvayli (teclistamab-cqyv) prior authorization policy for relapsed/refractory multiple myeloma, updated September 24, 2025. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires prior authorization before dispensing. Key requirements include: patient must have relapsed/refractory multiple myeloma, received at least 4 prior therapy lines (including anti-CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agent), and use Tecvayli as a single agent. Exclusion: patients with prior disease progression on BCMA-directed CD3 T-cell engager regimens are not approved.
Medium impact
Tecartus™ (brexucabtagene autoleucel) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Tecartus (brexucabtagene autoleucel) prior authorization policy for Medicaid-Louisiana effective January 1, 2023, with the most recent revision dated May 1, 2026. The policy covers CAR-T cell therapy for relapsed/refractory mantle cell lymphoma and acute lymphoblastic leukemia in adults ≥18 years, requiring prior authorization with specific clinical criteria and exclusions. One lifetime dose maximum applies with 60-day approval duration per treatment.
High impact
Rituximab Products (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage updated its Rituximab Products prior authorization policy effective January 1, 2023, with a revision date of June 24, 2026. The policy establishes step-therapy requirements for branded rituximab products (Rituxan, Truxima) across nine covered indications, requiring documented intolerance or contraindication to biosimilars (Ruxience, Riabni) before approval, with exceptions for continuation of prior therapy within 365 days. Key exclusions include high-dose CLL therapies and maintenance therapy duration limits (2 years for CLL and low-grade NHL).
Medium impact
Rituxan Hycela™ (rituximab/hyaluronidase) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its Rituxan Hycela (rituximab/hyaluronidase) prior authorization policy effective June 24, 2026, clarifying coverage criteria for chronic lymphocytic leukemia, follicular lymphoma, and diffuse large B cell lymphoma across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). Key changes include maintenance therapy duration limits (2-year maximum for CLL and follicular lymphoma) and exclusion of first-line single-agent use in follicular lymphoma. Billing teams must verify prior authorization requirements before claims submission to avoid denials.
Medium impact
Risperidone Orally Disintegrating Tablets (Revised)
Humana·Effective Jan 1, 2023
This is a step therapy policy for risperidone orally disintegrating tablets (Risperdal M-Tab) under Medicare Advantage plans. Coverage requires members to have previous treatment or documented intolerance with generic risperidone tablets before the disintegrating formulation will be approved. The policy was revised on February 25, 2026 with an effective date of January 1, 2023.
Medium impact
Rasuvo® (methotrexate injection) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicare Advantage prior authorization policy for Rasuvo® (methotrexate injection) effective January 1, 2023, with the most recent revision dated April 22, 2026. The policy maintains prior authorization requirements for three indications: rheumatoid arthritis (requires severe active disease and prior generic methotrexate trial/intolerance), polyarticular juvenile idiopathic arthritis (requires active disease and prior generic methotrexate trial/intolerance), and psoriasis (requires severe, recalcitrant, disabling disease and prior generic methotrexate trial/intolerance). Approval duration is granted in plan year intervals or as determined through clinical review.
Medium impact
Pyrukynd® (mitapivat) (Revised)
Humana·Effective Aug 27, 2025
Humana has revised its Medicare Advantage prior authorization policy for Pyrukynd® (mitapivat) effective August 27, 2025. The policy establishes specific genetic and clinical criteria for coverage: patients must have pyruvate kinase deficiency with at least two mutant alleles in the PKLR gene (at least one missense), cannot be homozygous for R479H mutation, and must have hemoglobin ≤10 g/dL. Prior authorization is required for all Pyrukynd tablets (5mg, 20mg, 50mg formulations).
High impact
Pediatric Day Health Care (PDHC) - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 1, 2023
This is a new Humana Louisiana Medicaid policy (effective 01/01/2023, most recently approved 01/20/2025) establishing coverage and prior authorization requirements for Pediatric Day Health Care (PDHC) services for medically complex children ages birth to 21. The policy mandates prior authorization, requires comprehensive documentation including physician orders and plans of care, and limits certification periods to 90 days with required face-to-face physician evaluations every 90 days (extendable to 180 days in exceptional circumstances).
Medium impact
Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Opdualag (nivolumab and relatlimab-rmbw) effective January 1, 2023, with updates as of March 25, 2026. The policy requires prior authorization for this combination immunotherapy in patients 12+ years with unresectable or metastatic melanoma as monotherapy. Key exclusions include disease progression on prior anti-PD-1/PD-L1 combination therapy and concurrent use with BRAF/MEK inhibitors. Initial and renewal authorizations are approved for 6 months or as determined through clinical review.
Medium impact
Onpattro® (patisiran) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its prior authorization policy for Onpattro® (patisiran) effective March 25, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. The policy maintains four strict approval criteria: TTR gene mutation documentation, confirmed polyneuropathy with other causes ruled out, polyneuropathy disability score IIIb or lower, and no prior liver transplant history. Billing teams must ensure all prior authorization requests include these four clinical criteria before claim submission to avoid denials.
High impact
Muscle Relaxants (Revised)
Humana·Effective Jan 1, 2023
Humana has revised its Muscle Relaxants step therapy policy (effective January 1, 2023, revised May 22, 2024) for Medicare Advantage plans. The policy now requires step therapy approval based on prior treatment criteria: members must have received previous treatment within the past 12 months with BOTH generic tizanidine tablets AND baclofen tablets before other muscle relaxants (Zanaflex, Amrix, chlorzoxazone, cyclobenzaprine ER, Fexmid, Lorzone, metaxalone, Lyvispah, orphenadrine injection) can be approved. Initial approvals are granted for the plan year duration or through clinical review.
High impact
Methotrexate Injection (Otrexup®, Reditrex®) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Medicare Advantage prior authorization policy for Methotrexate Injection (Otrexup and Reditrex) effective January 1, 2023, with the most recent revision dated April 22, 2026. The policy requires prior authorization for coverage of these injectable methotrexate formulations across three indications: severe active rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, and severe recalcitrant psoriasis. All requests must demonstrate previous treatment failure or documented intolerance to generic methotrexate before approval.
Medium impact
Methotrexate Injection (Otrexup®, Rasuvo®) (Revised)
Humana·Effective Jan 24, 2024
Humana revised its prior authorization policy for Methotrexate Injection (Otrexup and Rasuvo) effective January 24, 2024. The policy maintains three indications (Rheumatoid Arthritis, Polyarticular Juvenile Idiopathic Arthritis, and Psoriasis) with a consistent requirement: members must have previous treatment or documented intolerance with generic methotrexate (oral or injection) AND Reditrex before approval. Initial approvals are granted for plan year durations or as determined through clinical review.
High impact
Medical Necessity Determinations (Revised)
Humana·Effective Jan 1, 2023
Humana has revised its Medical Necessity Determinations policy for Louisiana Medicaid pharmacy coverage, effective January 1, 2023, with a revision date of November 26, 2025. The policy establishes a hierarchical framework for medical necessity review (state/federal requirements → Prime Therapeutics criteria → Humana criteria → approved compendia) and explicitly excludes experimental, non-FDA approved, investigational, and cosmetic services from coverage. This is a guidance document that standardizes how prior authorization and medical necessity decisions are made for pharmacy products.
Medium impact
Lotronex® (alosetron HCl) (Revised)
Humana·Effective Feb 28, 2024
Humana has revised its Lotronex (alosetron HCl) prior authorization policy effective February 28, 2024. This is a pharmacy coverage policy for Medicare Advantage and Commercial plans requiring prior authorization for Lotronex use in severe diarrhea-predominant IBS (IBS-D). The policy mandates that patients meet three strict criteria: diagnosis of severe IBS-D, chronic symptoms lasting 6+ months, and prior treatment failure or intolerance to both an antidiarrheal agent and a tricyclic antidepressant. Approval duration is for the initial plan year.
High impact
Liposomal doxorubicin (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana prior authorization policy for liposomal doxorubicin (Doxil, Lipodox) effective January 1, 2023, with the most recent revision dated May 27, 2026. The policy establishes specific prior authorization criteria across seven cancer indications (T-cell leukemia/lymphoma, diffuse large B-cell lymphoma, mycosis fungoides/Sezary syndrome, peripheral T-cell lymphoma, breast cancer, Hodgkin lymphoma, Kaposi's sarcoma, multiple myeloma, and ovarian cancer), with distinct approval requirements and combination therapy mandates for each diagnosis. All liposomal doxorubicin claims require prior authorization across Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid.
Medium impact
Levoleucovorin products (Revised)
Humana·Effective Sep 24, 2025
This is a revised Humana Medicaid (Louisiana) prior authorization policy for levoleucovorin products (Khapzory, Fusilev, and generics) effective January 1, 2023, with a revision date of September 24, 2025. The policy establishes prior authorization requirements for three indications: osteosarcoma treatment with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer. All three pathways require documented prior leucovorin calcium treatment and evidence of side effects due to lack of efficacy or formulation issues necessitating therapy change.
High impact
Kymriah™ (tisagenlecleucel) (Revised)
Humana·Effective May 1, 2026
Humana Louisiana Medicaid revised its Kymriah (tisagenlecleucel) prior authorization policy effective May 1, 2026. The policy maintains coverage for three indications (DLBCL, ALL, and Follicular Lymphoma) with updated approval criteria and exclusions. Key requirements include prior authorization through the Corporate Transplant Department, lymphodepleting chemotherapy regimens (unless contraindicated), and a maximum of one dose per lifetime. Multiple exclusions apply, including prior gene therapy, prior anti-CD19 therapy, active hepatitis B/C, HIV/AIDS, and prior allogeneic transplant for lymphoma patients.

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Archive by year

2023 2024 2025 2026

Yescarta™ (axicabtagene ciloleucel) (Revised)

Xofigo® (radium Ra 223 dichloride) (Revised)

Winlevi® (clascoterone) (Revised)

Vabysmo® (faricimab-svoa) (Revised)

Tykerb (lapatinib) (Revised)

Topical Tazarotene Products (Arazlo®, Fabior®) (Revised)

Topical Onychomycotic Agents (Revised)

Tecvayli (teclistamab-cqyv) (Revised)

Tecartus™ (brexucabtagene autoleucel) (Revised)

Rituximab Products (Revised)

Rituxan Hycela™ (rituximab/hyaluronidase) (Revised)

Risperidone Orally Disintegrating Tablets (Revised)

Rasuvo® (methotrexate injection) (Revised)

Pyrukynd® (mitapivat) (Revised)

Pediatric Day Health Care (PDHC) - MEDICAID - LOUISIANA (New)

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

Onpattro® (patisiran) (Revised)

Muscle Relaxants (Revised)

Methotrexate Injection (Otrexup®, Reditrex®) (Revised)

Methotrexate Injection (Otrexup®, Rasuvo®) (Revised)

Medical Necessity Determinations (Revised)

Lotronex® (alosetron HCl) (Revised)

Liposomal doxorubicin (Revised)

Levoleucovorin products (Revised)

Kymriah™ (tisagenlecleucel) (Revised)