All Insurance Policy Changes (Page 171)

Continuing from page 170. 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
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.
Medium impact
Jynarque® (tolvaptan) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicare Advantage prior authorization policy for Jynarque® (tolvaptan) for treating autosomal dominant polycystic kidney disease (ADPKD). The policy requires prior authorization for coverage and mandates that patients meet four specific criteria: ADPKD diagnosis, risk of rapidly progressive disease, CKD stage 2-4, and medication use to slow kidney function decline. The policy includes a black box warning regarding serious liver injury risk and requires mandatory liver function monitoring before treatment initiation and ongoing throughout therapy.
Medium impact
Istodax (romidepsin) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Istodax (romidepsin) prior authorization policy effective January 28, 2026 for Medicare and Medicaid (Florida, Kentucky, South Carolina). The policy requires prior authorization for romidepsin use in cutaneous T-cell lymphoma (CTCL), with approval contingent on the drug being used as primary biologic systemic therapy OR the member having received at least one prior therapy. Members with disease progression on romidepsin are excluded from coverage.
Medium impact
Icosapent Ethyl (generic Vascepa) (Revised)
Humana·Effective Jun 26, 2024
Humana revised its prior authorization policy for icosapent ethyl (generic Vascepa) effective June 26, 2024. The policy maintains two approval pathways: (1) Risk Reduction in patients with elevated triglycerides (≥150 mg/dL) who have established cardiovascular disease or Type 2 Diabetes with CV risk factors, requiring prior treatment/intolerance to brand Vascepa plus concurrent use of a generic statin, fenofibrate, or ezetimibe; and (2) Severe Triglyceridemia (≥500 mg/dL) requiring prior treatment/intolerance to brand Vascepa plus fenofibrate. All approvals are limited to initial plan year duration. The revision date indicates this is a recent update requiring immediate implementation.
Low impact
Hypomethylating agents (azacitidine, decitabine) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage has revised its prior authorization policy for hypomethylating agents (azacitidine and decitabine) effective January 1, 2023, with the most recent revision dated June 24, 2026. The policy requires prior authorization for these drugs when used to treat myelodysplastic syndrome (MDS), acute myelogenous leukemia (AML), or myeloproliferative neoplasms, with approval granted for the initial plan year or as determined through clinical review. This is a routine policy reaffirmation with no apparent changes to coverage criteria since the original effective date.
Medium impact
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) prior authorization policy effective June 24, 2026. The policy clarifies coverage criteria for HER2-positive breast cancer treatment in both adjuvant and metastatic settings, with step therapy requirements (prior trial of Kanjinti or Trazimera) now waived for Florida Medicaid requests. Key changes include explicit treatment combination pathways and exclusions for concomitant use with Kadcyla or gastric/GEJ/esophageal cancers.
Medium impact
Fycompa® (perampanel) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicare Advantage prior authorization policy for Fycompa (perampanel) effective January 1, 2023, with the most recent revision dated November 26, 2025. The policy establishes prior authorization requirements for two indications: partial-onset (focal) seizures requiring failure on at least two other antiepileptic drugs, and adjunctive treatment of generalized tonic-clonic seizures requiring combination therapy and prior failure on at least two other drugs. The policy includes a black box warning regarding serious psychiatric and behavioral adverse reactions requiring monitoring.
Medium impact
Eysuvis™ (loteprednol etabonate) (Revised)
Humana·Effective Jan 24, 2024
Humana revised its Eysuvis (loteprednol etabonate) prior authorization policy effective January 24, 2024. The policy maintains prior authorization requirement for this ophthalmic corticosteroid suspension used to treat dry eye disease, with approval granted for plan year durations or through clinical review. The single approval criterion remains a diagnosis of dry eye disease.
Medium impact
Evenity® (romosozumab-aqqg) (Revised)
Humana·Effective Jan 1, 2023
Humana revised its Evenity (romosozumab-aqqg) prior authorization policy effective January 1, 2023, with updates as of February 25, 2026. The policy applies to Medicaid and Medicare (South Carolina) and requires prior authorization for osteoporosis treatment in postmenopausal women at high or very high fracture risk. Critical change: The policy now limits Evenity to a maximum of 12 monthly doses and excludes patients with myocardial infarction or stroke within the preceding year due to black box cardiovascular warnings.
Low impact
Eulexin (Flutamide) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage has revised its prior authorization policy for Eulexin (Flutamide), a nonsteroidal antiandrogen used to treat prostate cancer. The policy requires prior authorization when flutamide is used alone or in combination with LHRH analogs, with coverage limited to members with a confirmed prostate cancer diagnosis. This is a routine policy revision with no substantive coverage changes from the effective date.
Medium impact
Esbriet® (pirfenidone) (Revised)
Humana·Effective Jan 1, 2023
This is a revision (updated January 28, 2026) to Humana's Medicare Advantage prior authorization policy for Esbriet® (pirfenidone) for idiopathic pulmonary fibrosis treatment. The policy requires documentation of pulmonary fibrosis via CT scan showing usual interstitial pneumonia (UIP) or surgical lung biopsy, plus exclusion of alternative diagnoses before approval. No substantive coverage changes are noted in this revision; this appears to be a routine policy refresh.
High impact
Enhertu (fam-trastuzumab deruxtecan-nxki) (Revised)
Humana·Effective Jan 1, 2023
Humana revised its Enhertu (fam-trastuzumab deruxtecan-nxki) prior authorization policy effective January 1, 2023, with the most recent revision on March 25, 2026. The policy covers six oncology indications with specific clinical criteria, prior treatment requirements, and HER2 status specifications. Billing teams must verify prior authorization eligibility before claims submission across multiple Medicaid state programs and Medicare.
Medium impact
Elzonris™ (tagraxofusp-erzs) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Elzonris (tagraxofusp-erzs) prior authorization policy for Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) treatment, effective January 1, 2023, with the most recent revision dated January 28, 2026. The policy requires prior authorization for all Elzonris intravenous infusions and mandates that patients meet three criteria: confirmed BPDCN diagnosis per WHO classification, ability to remain inpatient for the complete first course of therapy plus 24 hours observation, and age 2 years or older. The policy applies to Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina).
Medium impact
Elahere (mirvetuximab soravtansine-gynx) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its prior authorization policy for Elahere (mirvetuximab soravtansine-gynx) effective March 25, 2026, for treatment of platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer. The policy now applies across Medicare, Medicaid (Florida, Kentucky, South Carolina), and requires prior authorization confirmation of five clinical criteria including folate receptor alpha expression testing, prior treatment history, and single-agent use. Billing teams must verify all five approval criteria are met before claim submission or face denial.
Medium impact
Dopamine Agonists (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage updated its Dopamine Agonists step therapy policy (revised 11/26/2025). The policy requires members to have tried or be unable to use immediate-release pramipexole AND immediate-release ropinirole before approval for extended-release formulations (Mirapex ER, pramipexole ER, ropinirole ER) or Neupro patches. This is a step therapy requirement that mandates prior authorization for these medications.
Medium impact
Differin® (adapalene) and Epiduo® (adapalene and benzoyl peroxide) (Revised)
Humana·Effective Jan 1, 2023
Humana has revised its pharmacy coverage policy for Differin (adapalene) and Epiduo (adapalene and benzoyl peroxide) effective January 1, 2023, with updates as of April 24, 2024. This is a step therapy policy requiring members to have prior treatment with or documented intolerance to at least two of the following: tretinoin (non-micro), adapalene 0.1% gel, or adapalene-benzoyl peroxide 0.1%-2.5% before coverage is approved. The policy covers multiple formulations and strengths across topical gels, creams, lotions, solutions, and swabs.
Medium impact
Diacomit® (stiripentol) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage has updated its prior authorization policy for Diacomit® (stiripentol) effective January 1, 2023, with a recent revision dated October 22, 2025. The policy requires prior authorization for Diacomit use in Dravet syndrome patients and mandates four specific clinical criteria be met: diagnosed Dravet syndrome with seizures, specialist prescription, documented refractory seizures within 28 days, and concurrent clobazam therapy. Billing teams must ensure all Diacomit claims include prior authorization and verify all four approval criteria are documented before claim submission.
Medium impact
Dexilant® (dexlansoprazole) (Revised)
Humana·Effective Feb 28, 2024
Humana Medicare Advantage has revised its Dexilant (dexlansoprazole) pharmacy coverage policy, effective February 28, 2024. This is a step therapy policy requiring members to have previous treatment with or intolerance to at least two specific proton pump inhibitors (omeprazole, pantoprazole, or esomeprazole) before Dexilant coverage is approved. Billing teams must verify step therapy requirements are met before submitting claims to avoid denials.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 171) | PolicyChanges.app

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)

Jynarque® (tolvaptan) (Revised)

Istodax (romidepsin) (Revised)

Icosapent Ethyl (generic Vascepa) (Revised)

Hypomethylating agents (azacitidine, decitabine) (Revised)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)

Fycompa® (perampanel) (Revised)

Eysuvis™ (loteprednol etabonate) (Revised)

Evenity® (romosozumab-aqqg) (Revised)

Eulexin (Flutamide) (Revised)

Esbriet® (pirfenidone) (Revised)

Enhertu (fam-trastuzumab deruxtecan-nxki) (Revised)

Elzonris™ (tagraxofusp-erzs) (Revised)

Elahere (mirvetuximab soravtansine-gynx) (Revised)

Dopamine Agonists (Revised)

Differin® (adapalene) and Epiduo® (adapalene and benzoyl peroxide) (Revised)

Diacomit® (stiripentol) (Revised)

Dexilant® (dexlansoprazole) (Revised)