All Insurance Policy Changes (Page 174)

Continuing from page 173. 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
Litfulo™ (ritlecitinib) (Revised)
Humana·Effective Sep 27, 2023
Humana Medicare Advantage has revised its prior authorization policy for Litfulo™ (ritlecitinib) effective September 27, 2023, with updates as of September 24, 2025. The policy requires prior authorization for this JAK inhibitor used to treat severe alopecia areata, with specific clinical criteria including ≥50% scalp hair loss (SALT score), prior treatment failure/intolerance to corticosteroids or cyclosporine, and prohibition of concurrent use with other JAK inhibitors or potent immunosuppressants. Billing teams must ensure all Litfulo requests include prior authorization and verification of the three approval criteria before claim submission.
Medium impact
Joenja® (leniolisib) (Revised)
Humana·Effective Sep 27, 2023
Humana has updated its prior authorization policy for Joenja® (leniolisib) for Medicare Advantage members with activated phosphoinositide 3-kinase delta syndrome (APDS). The policy requires confirmed genetic mutation documentation (PIK3CD or PIK3R1) and prescriber specialty verification before approval. Initial authorization is valid for 6 months, with renewal based on documented clinical benefit.
Medium impact
Izervay™ (avacincaptad pegol) (Revised)
Humana·Effective Dec 17, 2025
Humana has updated its prior authorization policy for Izervay™ (avacincaptad pegol), a complement inhibitor intravitreal injection for geographic atrophy secondary to age-related macular degeneration. The revised policy (effective December 17, 2025) requires prior authorization for Medicare and Medicaid members in Kentucky and South Carolina, with approval based on GA diagnosis and prescription by an ophthalmologist or retinal specialist. Billing teams must implement prior auth requirements and ensure provider specialty verification before claim submission.
Medium impact
Elevidys (delandistrogene moxeparvovec-rokl) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Elevidys (delandistrogene moxeparvovec-rokl) prior authorization policy effective December 17, 2025, for a gene therapy treatment of Duchenne Muscular Dystrophy. The policy requires comprehensive prior authorization with 11 strict clinical criteria including DMD diagnosis confirmation, ambulatory status verification via NSAA assessment, specific genetic testing, baseline lab work, antibody titers, and exclusions for prior gene therapy or antisense oligonucleotide use. Coverage is limited to a single lifetime dose with initial 6-month approval and one 6-month renewal.
Medium impact
Columvi™ (glofitamab-gxbm) (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Columvi (glofitamab-gxbm) prior authorization policy effective February 25, 2026, covering Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. The policy maintains prior authorization requirements for this bispecific antibody used to treat relapsed/refractory diffuse large B-cell lymphoma in patients who have received two or more prior systemic therapies. No substantive coverage criteria changes are noted; this appears to be a routine policy review and update.
Medium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Elrexfio (elranatamab-bcmm) prior authorization policy effective September 24, 2025. This is a pharmacy coverage policy for relapsed/refractory multiple myeloma requiring prior auth. The policy applies to Medicare and three state Medicaid programs (FL, KY, SC). Key requirements include: patient must have received ≥4 prior lines of therapy including specific drug classes, Elrexfio must be used as monotherapy, and patients with prior BCMA-directed CD3 T-cell engager progression are excluded. Billing teams must implement prior authorization controls for this drug across affected plans.
Medium impact
Ycanth™ (cantharidin) (Revised)
Humana·Effective Nov 22, 2023
Humana has updated its prior authorization policy for Ycanth™ (cantharidin) for treating molluscum contagiosum in Medicare Advantage members. The revised policy (effective November 22, 2023, revised October 22, 2025) requires prior authorization and mandates that members must have failed or been intolerant to conventional therapies (podofilox, cimetidine, imiquimod) before approval. Billing teams must ensure all Ycanth claims include documentation of previous treatment attempts or contraindications to qualify for coverage.
High impact
Talvey (talquetamab) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Talvey (talquetamab) prior authorization policy effective September 24, 2025, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains strict approval criteria requiring multiple myeloma diagnosis, relapsed/refractory disease, at least four prior therapy lines (including specific drug classes), and single-agent use only. A key exclusion applies: members experiencing disease progression on Talvey are not approved. Billing teams must ensure all Talvey claims include prior authorization and verify patient meets all four criteria before claim submission.
Medium impact
Motpoly XR (lacosamide extended release) (Revised)
Humana·Effective Aug 27, 2025
Humana Medicare Advantage updated the Motpoly XR (lacosamide extended-release) prior authorization policy effective August 27, 2025. The policy requires prior authorization for seizure treatment with specific clinical criteria: patients must have documented failure with generic lacosamide AND at least one other antiepileptic drug, weigh at least 50 kg, and meet diagnosis requirements for either partial-onset seizures or adjunctive generalized tonic-clonic seizure treatment.
Medium impact
Ilumya® (tildrakizumab) (Revised)
Humana·Effective May 27, 2026
Humana revised its Ilumya (tildrakizumab) prior authorization policy for Medicare and Medicaid (South Carolina) effective May 27, 2026. The policy now requires step therapy with TNF inhibitors (Remicade/Inflectra/Infliximab) AND a preferred ustekinumab product (Stelara/Otulfi/Yesintek) before Ilumya approval, with an exception for Medicare Part B continuation therapy within 365 days. Combination therapy with other biologics remains excluded.
Medium impact
Ilumya® (tildrakizumab) (Revised)
Humana·Effective Sep 25, 2024
Humana updated its Ilumya (tildrakizumab) prior authorization policy effective September 25, 2024. The policy maintains existing coverage criteria for moderate to severe plaque psoriasis but emphasizes mandatory prior authorization, strict failure/intolerance requirements for two specific biologic classes (TNF inhibitors and Stelara), and explicit exclusion of combination biologic therapy. Billing teams must ensure all Ilumya requests meet these tightened criteria before submission.
Medium impact
Air Ambulance Transportation (AAT) - MEDICAID - LOUISIANA (New)
Humana·Effective Nov 25, 2023
Humana Louisiana Medicaid updates air ambulance transportation (AAT) coverage requirements, effective 11/25/2023. Emergency air ambulance services require NO prior authorization, while all non-emergency air ambulance services now require prior authorization and must meet specific medical necessity criteria. Outpatient air ambulance services (emergent or non-emergent) are not covered. Billing teams must distinguish between emergency and non-emergency transports to correctly apply authorization requirements.
Medium impact
Lodoco® (colchicine) (Revised)
Humana·Effective Dec 20, 2023
Humana Medicare Advantage has revised its Prior Authorization policy for Lodoco® (colchicine) effective December 20, 2023, with the most recent revision dated November 26, 2025. This is a pharmacy coverage policy requiring prior authorization for colchicine use in Medicare Advantage members with atherosclerotic cardiovascular disease (ASCVD) who meet specific clinical criteria including maximally tolerated statin therapy and optimization on standard cardiovascular medications.
Medium impact
Zilretta® (triamcinolone acetonide extended-release injectable suspension) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Zilretta (triamcinolone acetonide extended-release) prior authorization policy effective January 28, 2026. Key changes include clarification that step therapy requirements (prior failure with two short-acting intra-articular steroids) do not apply to Florida Medicaid, and Medicare Part B continuation therapy within 365 days is exempted from step therapy. The policy maintains strict criteria: documented knee osteoarthritis, no prior Zilretta use in the same knee, and (except for Florida Medicaid) inadequate response to two different short-acting intra-articular steroids.
Medium impact
Zavzpret™ (zavegepant) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has implemented a prior authorization requirement for Zavzpret (zavegepant) nasal spray for acute migraine treatment. Coverage requires documented failure, intolerance, or contraindication to both sumatriptan nasal spray AND Ubrelvy before approval. This is a CGRP receptor antagonist with a maximum 24-hour dose of 10 mg and safety data only supporting treatment of up to 8 migraines per 30-day period.
Medium impact
Zaltrap (ziv-aflibercept) (Revised)
Humana·Effective Jan 1, 2024
Humana revised its Zaltrap (ziv-aflibercept) prior authorization policy effective January 1, 2024, with the most recent update on November 26, 2025. The policy clarifies coverage criteria for this VEGF inhibitor in metastatic colorectal cancer, requiring prior authorization and specifying that it must be used as second-line therapy following oxaliplatin-containing regimen failure or in specific unresectable metastatic scenarios. Claims will be denied if prior authorization is not obtained or if the member experiences disease progression while on Zaltrap.
High impact
Xolair® (omalizumab) (Revised)
Humana·Effective Jan 1, 2024
This is a revised Humana Medicare Advantage prior authorization policy for Xolair (omalizumab) effective January 1, 2024, with the most recent revision dated March 25, 2026. The policy covers four indications: chronic idiopathic urticaria (age 12+), moderate to severe persistent asthma (age 6+), nasal polyps (age 18+), and IgE-mediated food allergy (age 1+). All Xolair prescriptions require prior authorization with specific clinical criteria that must be met before approval.
Medium impact
Xifaxan® (rifaximin) (Revised)
Humana·Effective Jan 1, 2024
This is a revised Humana Medicare Advantage prior authorization policy for Xifaxan® (rifaximin) effective January 1, 2024, with the most recent revision dated June 24, 2026. The policy establishes prior authorization requirements for three indications: IBS-D (requires diagnosis confirmation and age ≥18), travelers' diarrhea (requires non-invasive E. coli confirmation, no fever/blood in stool, age ≥12, and failure of fluoroquinolones/azithromycin), and hepatic encephalopathy recurrence prevention (requires prior HE episode, age ≥18). All approvals are limited to plan year duration with renewal requirements.
High impact
Xgeva® (denosumab) and biosimilars (Revised)
Humana·Effective Jan 1, 2024
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Xgeva (denosumab) and six biosimilars effective January 1, 2024, with a revision date of May 1, 2026. The policy covers four indications—hypercalcemia of malignancy, osteolytic bone metastases, multiple myeloma, and giant cell tumor of bone—each with specific clinical criteria and a critical exclusion: concurrent bisphosphonate therapy is not permitted. Billing teams must ensure prior authorization is obtained before claims are submitted and verify all clinical criteria are met.
Medium impact
Xeomin® (incobotulinumtoxinA) (Revised)
Humana·Effective Jan 1, 2024
Humana has revised its Xeomin (incobotulinumtoxinA) prior authorization policy for Kentucky Medicaid and Medicare effective January 1, 2024, with updates as of June 24, 2026. The policy clarifies four covered medical indications (blepharospasm, cervical dystonia, chronic sialorrhea, and upper limb spasticity in adults and select pediatric patients) while maintaining explicit exclusions for cosmetic uses and non-approved conditions. Prior authorization is required for all Xeomin claims under this policy.
Medium impact
Vizimpro (dacomitinib) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage updated its Vizimpro (dacomitinib) prior authorization policy effective January 1, 2024, with a recent revision dated January 28, 2026. The policy requires prior authorization for Vizimpro as a single-agent, first-line treatment for metastatic NSCLC in patients with documented EGFR exon 19 deletion or exon 21 (L858R) mutation. Initial approval is for 6 months with 6-month renewals.
Medium impact
Visudyne® (verteporfin) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicaid-Louisiana has revised its Visudyne (verteporfin) prior authorization policy effective January 1, 2024, with the most recent revision dated February 25, 2026. The policy establishes specific prior authorization criteria for three indications: neovascular age-related macular degeneration (requiring prior therapy/contraindication/intolerance to bevacizumab), presumed ocular histoplasmosis, and pathologic myopia. All Visudyne IV therapy now requires prior authorization with approval granted for plan year duration initially and renewals.
High impact
Viscosupplements (Revised)
Humana·Effective Jan 1, 2024
Humana Medicaid (Louisiana) has implemented a revised prior authorization policy for viscosupplements effective January 1, 2024, with a recent revision date of March 1, 2026. Coverage is now limited to knee osteoarthritis only, requires documented failure of two specific first-line products (Durolane, Euflexxa, Gelsyn-3, or Supartz FX) before approving alternative viscosupplement products, and mandates a 6-month interval between treatment cycles. All viscosupplement injections require prior authorization before administration.
Medium impact
Viscosupplements (Revised)
Humana·Effective Jan 28, 2026
Humana revised its viscosupplement prior authorization policy effective January 28, 2026, for four Medicaid state programs (FL, KY, SC, VA). The policy maintains prior authorization requirements for 18 viscosupplement products used to treat knee osteoarthritis, with specific clinical criteria including documented symptomatic knee OA, previous treatment/contraindication/intolerance with two specified products (except Florida), and 6-month intervals between treatment cycles. This is a routine policy revision with no substantive coverage changes.
Medium impact
Viibryd® (vilazodone) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage updated its prior authorization policy for Viibryd® (vilazodone) effective January 1, 2024, with a revision date of April 22, 2026. The policy requires prior authorization for vilazodone treatment of major depressive disorder, with mandatory documentation of prior therapy or documented intolerance/contraindication to SSRIs AND either generic bupropion or mirtazapine before approval. This is a revised policy (not new), indicating coverage criteria have been clarified or modified from a prior version.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

Litfulo™ (ritlecitinib) (Revised)

Joenja® (leniolisib) (Revised)

Izervay™ (avacincaptad pegol) (Revised)

Elevidys (delandistrogene moxeparvovec-rokl) (Revised)

Columvi™ (glofitamab-gxbm) (Revised)

Elrexfio (elranatamab-bcmm) (Revised)

Ycanth™ (cantharidin) (Revised)

Talvey (talquetamab) (Revised)

Motpoly XR (lacosamide extended release) (Revised)

Ilumya® (tildrakizumab) (Revised)

Ilumya® (tildrakizumab) (Revised)

Air Ambulance Transportation (AAT) - MEDICAID - LOUISIANA (New)

Lodoco® (colchicine) (Revised)

Zilretta® (triamcinolone acetonide extended-release injectable suspension) (Revised)

Zavzpret™ (zavegepant) (Revised)

Zaltrap (ziv-aflibercept) (Revised)

Xolair® (omalizumab) (Revised)

Xifaxan® (rifaximin) (Revised)

Xgeva® (denosumab) and biosimilars (Revised)

Xeomin® (incobotulinumtoxinA) (Revised)

Vizimpro (dacomitinib) (Revised)

Visudyne® (verteporfin) (Revised)

Viscosupplements (Revised)

Viscosupplements (Revised)

Viibryd® (vilazodone) (Revised)