All Insurance Policy Changes (Page 176)

Continuing from page 175. 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
Xyrem® (sodium oxybate) (Revised)
Humana·Effective Jan 1, 2025
This is a revised Humana Medicare Advantage prior authorization policy for Xyrem® (sodium oxybate) effective January 1, 2025, with updates through March 25, 2026. The policy establishes coverage criteria for two narcolepsy indications: narcolepsy with cataplexy and narcolepsy with excessive daytime sleepiness (EDS). Key requirements include documented diagnosis, previous treatment/intolerance to generic sodium oxybate for brand requests, and exclusivity (no concurrent use with related medications). Billing teams must ensure prior authorization is obtained before claims are submitted, and providers must document clinical criteria met.
Medium impact
Xultophy® (insulin degludec and liraglutide) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has revised its prior authorization policy for Xultophy® (insulin degludec and liraglutide) effective January 1, 2025, with a revision date of April 22, 2026. The policy requires prior authorization for all Xultophy prescriptions and establishes five clinical approval criteria, including a new requirement that patients must have previous treatment with Soliqua before Xultophy can be approved. Billing teams must verify all five criteria are met before processing claims to avoid denials.
High impact
Xiidra® (lifitegrast ophthalmic solution) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has revised its Xiidra (lifitegrast ophthalmic solution) pharmacy coverage policy effective January 1, 2025, with an update dated June 25, 2025. The policy requires prior authorization for Xiidra and mandates that patients must have documented previous treatment, contraindication, or intolerance to BOTH cyclosporine eye drops (generic Restasis) AND Eysuvis (loteprednol) before approval. Approvals are granted for the plan year duration or as determined through clinical review.
Medium impact
Xcopri® (cenobamate) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage revised its Xcopri (cenobamate) prior authorization policy effective January 1, 2025, with updates finalized May 27, 2026. The policy requires prior authorization for Xcopri tablets and maintenance/titration packs for Medicare Advantage members with partial-onset seizures who have failed at least two other antiepileptic drugs. Billing teams must ensure all Xcopri claims include documented evidence of prior treatment failure before submission.
Medium impact
Xatmep™ (methotrexate) oral solution (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has updated its prior authorization policy for Xatmep™ (methotrexate) oral solution, effective January 1, 2025, with a revision dated October 22, 2025. The policy covers two pediatric indications: acute lymphoblastic leukemia (ALL) in patients under 18 as part of combination chemotherapy maintenance, and polyarticular juvenile idiopathic arthritis (pJIA) in patients under 18 with prior treatment failure or intolerance to generic methotrexate. Prior authorization is required for all Xatmep claims under this Medicare Advantage plan.
Medium impact
Wakix® (pitolisant) (Revised)
Humana·Effective Jan 1, 2025
Humana has revised its Wakix® (pitolisant) prior authorization policy for Medicare Advantage members, effective January 1, 2025, with the most recent revision dated February 25, 2026. The policy establishes specific clinical criteria for coverage of Wakix for two indications: excessive daytime sleepiness (EDS) with narcolepsy and cataplexy with narcolepsy. Key requirements include documented narcolepsy diagnosis per ICSD-3/DSM-5, sleep testing confirmation, no QT prolongation risk factors, prior treatment failure with CNS stimulants and modafinil/armodafinil, and restriction to one competing medication at a time. Prior authorization is required for all Wakix requests.
Medium impact
Vyondys 53 (golodirsen) (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its Vyondys 53 (golodirsen) prior authorization policy effective January 1, 2025, with a revision date of May 27, 2026. This policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires prior authorization for this antisense oligonucleotide therapy used to treat Duchenne Muscular Dystrophy in patients with exon 53-amenable mutations. Billing teams must implement prior authorization requirements and ensure all seven initial approval criteria and renewal criteria are documented and submitted before claims can be processed.
Medium impact
Vyepti® (eptinezumab) (Revised)
Humana·Effective Jan 1, 2025
Humana has revised its Vyepti (eptinezumab) prior authorization policy effective January 1, 2025, with updates published October 8, 2025. The policy now requires step therapy—prior treatment with both Emgality AND Qulipta—before Vyepti approval for Medicare Advantage members, with exceptions for Medicare Part B continuation therapy and PDP/MA-only plans. Billing teams must implement step therapy verification and prior authorization workflows immediately.
High impact
Vraylar (cariprazine) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has issued a revised prior authorization policy for Vraylar (cariprazine) effective January 1, 2025, with updates as of January 28, 2026. The policy establishes specific prior authorization requirements for four indications: schizophrenia (age 13+, requires 2 prior antipsychotic failures), bipolar I manic/mixed episodes (age 10+, requires 2 prior antipsychotic failures), bipolar I depression (requires prior quetiapine or lurasidone failure), and major depressive disorder as adjunctive therapy (requires prior antidepressant and atypical antipsychotic adjunct trials). All approvals are granted for plan year duration with renewal options.
Medium impact
Vowst (fecal microbiota spores, live-brpk) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has implemented a new Prior Authorization requirement for Vowst (fecal microbiota spores, live-brpk), effective January 1, 2025. The policy requires prior authorization for this medication when used to prevent recurrent Clostridioides difficile infection (CDI), with three specific clinical criteria that must be met: prior CDI episode, completion of standard CDI treatment (vancomycin or fidaxomicin), and bowel cleanse preparation. This is a pharmacy coverage policy requiring approval before dispensing.
Medium impact
Voquezna® (vonoprazan) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has issued a revised prior authorization policy for Voquezna (vonoprazan) effective January 1, 2025, with updates as of August 27, 2025. The policy establishes specific prior auth requirements for three indications: erosive esophagitis (requires 8-week PPI trial failure + endoscopy confirmation + gastroenterologist involvement), H. pylori infection (requires positive test + combination antibiotic therapy + Talicia failure/contraindication), and non-erosive GERD (requires 4-week max duration + documented PPI intolerance/contraindication to two agents + frequent heartburn). All prescriptions require prior authorization before dispensing.
Medium impact
Vivjoa® (oteseconazole) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has implemented a revised prior authorization policy for Vivjoa® (oteseconazole), a new antifungal treatment for recurrent vulvovaginal candidiasis (RVVC). The policy requires four strict approval criteria including confirmation of ≥3 RVVC episodes in the past year, non-reproductive potential status, and prior treatment failure or intolerance to fluconazole maintenance therapy. Billing teams must implement prior authorization requirements before dispensing this newly approved medication.
Medium impact
Visudyne® (verteporfin) (Revised)
Humana·Effective Jan 1, 2025
Humana revised its Visudyne (verteporfin) prior authorization policy effective January 1, 2025, with the latest revision dated February 25, 2026. The policy now applies to four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia) and specifies prior authorization requirements for three indications: neovascular age-related macular degeneration (with a bevacizumab prior therapy/contraindication/intolerance requirement, except in Florida), presumed ocular histoplasmosis, and pathologic myopia. All uses require plan year-based prior authorization approval.
High impact
Vesicare and Vesicare LS (solifenacin) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage updated its prior authorization policy for Vesicare and Vesicare LS (solifenacin) effective January 1, 2025, with a revision dated February 25, 2026. The policy establishes two distinct approval pathways: one requiring prior failure/contraindication/intolerance with TWO agents (oxybutynin IR/ER, solifenacin, Myrbetriq, or Gemtesa) for overactive bladder, and another requiring prior failure with BOTH oxybutynin AND Myrbetriq OR age under 3 years for neurogenic detrusor overactivity. All Vesicare prescriptions now require prior authorization before dispensing.
High impact
Zepbound® (tirzepatide) (Revised)
Humana·Effective Jan 20, 2025
Humana Medicare Advantage has revised its prior authorization policy for Zepbound (tirzepatide) to cover a NEW indication: moderate to severe obstructive sleep apnea (OSA) in adults with obesity. Previously, Zepbound was only approved for weight loss; this expansion requires prior authorization based on specific OSA diagnostic criteria (AHI/REI ≥15, BMI ≥30, documented lifestyle modifications). Billing teams must implement prior auth requirements for all Zepbound claims under this new OSA indication effective immediately.
High impact
Wound Care - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 20, 2025
Humana Louisiana Medicaid (Healthy Horizons) implemented a new wound care prior authorization policy effective 01/20/2025. Wound care supplies now require prior authorization for three-month periods with specific documentation requirements (wound measurements, drainage, color, prescribed regimen, etc.), and wound care systems require PA for Stage III/IV chronic wounds or post-surgical conditions. Home health agency involvement is now mandatory for wound care supply approval.
Medium impact
Ziihera (zanidatamab-hrii) (Revised)
Humana·Effective Jan 22, 2025
Humana has issued a revised prior authorization policy for Ziihera (zanidatamab-hrii), a HER2-directed bispecific antibody for treating previously treated, unresectable or metastatic HER2-positive (IHC 3+) biliary tract cancer. The policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina plans and requires prior authorization confirming unresectable/metastatic BTC diagnosis, HER2-positive status (IHC 3+), at least one prior line of therapy (gemcitabine-based regimen), and monotherapy use. Claims will be denied if the member has experienced disease progression on Ziihera.
Medium impact
Vyalev® (foscarbidopa/foslevodopa) (Revised)
Humana·Effective Feb 26, 2025
Humana has issued a revised Medicare Advantage prior authorization policy for Vyalev® (foscarbidopa/foslevodopa) effective February 26, 2025. The policy requires prior authorization for this continuous subcutaneous infusion therapy for advanced Parkinson's disease patients with motor fluctuations uncontrolled by optimized carbidopa/levodopa and who have tried or cannot use specific adjunctive anti-Parkinson agents (COMT inhibitors, MAO-B inhibitors, dopamine agonists, or amantadine). Claims submitted without meeting all four criteria will be denied.
Medium impact
Wheelchair, Wheelchair Repairs, Standing Frame, and Patient Lift - MEDICAID - LOUISIANA (New)
Humana·Identified Jun 25, 2026
Failed to analyze policy change
Medium impact
Xromi oral solution (Revised)
Humana·Effective Apr 23, 2025
Humana has updated its prior authorization policy for Xromi oral solution (hydroxyurea) effective April 23, 2025. This is a revised Medicare Advantage pharmacy policy requiring prior authorization for sickle cell anemia treatment. The policy requires members to have a diagnosis of sickle cell anemia with recurrent moderate to severe pain crises AND prior treatment or intolerance with hydroxyurea capsule before approval.
Medium impact
Vykat XR (diazoxide choline) (Revised)
Humana·Effective Jun 25, 2025
Humana Medicare Advantage has established a new prior authorization policy for Vykat XR (diazoxide choline) effective June 25, 2025, for treating hyperphagia in Prader-Willi syndrome patients. The policy requires four mandatory approval criteria: PWS diagnosis confirmed by genetic testing showing chromosome 15q11-q13 abnormality, documented hyperphagia symptoms, and prescribing by a PWS specialist. All Vykat XR claims must obtain prior authorization before dispensing.
High impact
Virginia Short Acting Opioid Days Supply (Revised)
Humana·Effective Jul 1, 2025
Effective July 1, 2025, Humana Virginia Medicaid implements strict quantity limits on short-acting opioids: members can receive a maximum 7-day supply without prior authorization, with subsequent claims limited to 7 days (14 days total every 60 days) and capped at 60 MME per day. Prior authorization is required for any claims exceeding these thresholds or for members without qualifying diagnoses (HIV/AIDS, cancer, chronic pain conditions, palliative/hospice care, or long-term care residents).
Medium impact
Zilxi® (minocycline) Topical Foam (New)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage has implemented a new prior authorization requirement for Zilxi® (minocycline) topical foam, effective July 23, 2025. Providers must document that patients have failed or have contraindications to topical metronidazole AND non-delayed release oral doxycycline before Zilxi can be approved for treating inflammatory lesions of rosacea. Claims submitted without meeting all three criteria will require prior authorization.
Medium impact
Zusduri (mitomycin)
Humana·Effective Aug 27, 2025
Humana has established a new prior authorization policy for Zusduri (mitomycin) intravesical treatment effective August 27, 2025, covering Medicare and Medicaid members in Kentucky and South Carolina. The policy requires prior authorization for initial treatment (maximum 6 doses over 6 months) and renewal periods for patients with recurrent low-grade intermediate-risk non-muscle invasive bladder cancer, with specific clinical criteria and exclusions that must be met for approval.
Medium impact
Zelsuvmi™ (berdazimer) (New)
Humana·Effective Aug 27, 2025
Humana has established a new prior authorization policy for Zelsuvmi (berdazimer) topical gel, effective August 27, 2025, for the treatment of molluscum contagiosum in Medicare Advantage members. Coverage requires two criteria: confirmed diagnosis of molluscum contagiosum AND prior treatment failure, contraindication, or intolerance with conventional therapies (podofilox, cimetidine, or imiquimod). Billing teams must implement prior authorization requirements immediately.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 176) | PolicyChanges.app

Xyrem® (sodium oxybate) (Revised)

Xultophy® (insulin degludec and liraglutide) (Revised)

Xiidra® (lifitegrast ophthalmic solution) (Revised)

Xcopri® (cenobamate) (Revised)

Xatmep™ (methotrexate) oral solution (Revised)

Wakix® (pitolisant) (Revised)

Vyondys 53 (golodirsen) (Revised)

Vyepti® (eptinezumab) (Revised)

Vraylar (cariprazine) (Revised)

Vowst (fecal microbiota spores, live-brpk) (Revised)

Voquezna® (vonoprazan) (Revised)

Vivjoa® (oteseconazole) (Revised)

Visudyne® (verteporfin) (Revised)

Vesicare and Vesicare LS (solifenacin) (Revised)

Zepbound® (tirzepatide) (Revised)

Wound Care - MEDICAID - LOUISIANA (New)

Ziihera (zanidatamab-hrii) (Revised)

Vyalev® (foscarbidopa/foslevodopa) (Revised)

Wheelchair, Wheelchair Repairs, Standing Frame, and Patient Lift - MEDICAID - LOUISIANA (New)

Xromi oral solution (Revised)

Vykat XR (diazoxide choline) (Revised)

Virginia Short Acting Opioid Days Supply (Revised)

Zilxi® (minocycline) Topical Foam (New)

Zusduri (mitomycin)

Zelsuvmi™ (berdazimer) (New)