All Insurance Policy Changes (Page 178)

Continuing from page 177. 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
Zemaira® (alpha-1 proteinase inhibitor) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana prior authorization policy for Zemaira (alpha-1 proteinase inhibitor) effective January 1, 2026, with a June 24, 2026 revision date. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and requires prior authorization for coverage. Key approval criteria include diagnosis of congenital alpha-1 antitrypsin deficiency with clinically evident emphysema, specific phenotypes (PiZZ, PiZ(null), Pi(null,null)), and serum alpha-1 antitrypsin concentrations below defined thresholds. Exclusion applies to IgA-deficient members with antibodies against IgA.
High impact
Zelboraf (vemurafenib) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has revised its Zelboraf (vemurafenib) prior authorization policy effective January 1, 2026, with updates finalized April 22, 2026. The policy now covers two indications: unresectable/Stage IV metastatic melanoma with documented BRAF V600 mutation (as monotherapy or with Cotellic), and Erdheim-Chester Disease with BRAF V600 mutation (monotherapy only). Critical exclusions include concomitant use of specific immunotherapies and BRAF/MEK inhibitors, and prior disease progression on Zelboraf or anti-BRAF/MEK combination therapy. Billing teams must verify BRAF mutation documentation and drug interaction status before claim submission to avoid denials.
Medium impact
Zejula (niraparib) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage revised its Zejula (niraparib) prior authorization policy effective January 1, 2026, with updates finalized February 25, 2026. The policy covers niraparib for first-line and subsequent-line maintenance therapy in ovarian, fallopian tube, and primary peritoneal cancer patients with specific HRD-positive status and treatment response criteria. Key requirement: members with prior PARP inhibitor progression are excluded from coverage, and bevacizumab must be discontinued before initiating subsequent-line maintenance therapy.
Medium impact
Zaltrap (ziv-aflibercept) (New)
Humana·Effective Jan 1, 2026
Humana Indiana Medicaid has implemented a NEW prior authorization requirement for Zaltrap (ziv-aflibercept) effective January 1, 2026. This angiogenesis inhibitor for metastatic colorectal cancer now requires approval before dispensing, with specific clinical criteria including second-line therapy status, documented disease progression on oxaliplatin regimens, or unresectable metachronous metastases. Claims will be denied without prior authorization.
Medium impact
Zaltrap (ziv-aflibercept) (New)
Humana·Effective Jan 1, 2026
Humana Louisiana Medicaid has implemented a new prior authorization policy for Zaltrap (ziv-aflibercept) effective January 1, 2026. The policy requires prior auth for this cancer drug when used to treat metastatic colorectal cancer in combination with irinotecan/FOLFIRI chemotherapy, with specific criteria around second-line therapy and prior treatment history. Claims will be denied without proper authorization.
Medium impact
Zaltrap (ziv-aflibercept) (New)
Humana·Effective Jan 1, 2026
Humana Ohio Medicaid has established a new prior authorization requirement for Zaltrap (ziv-aflibercept) effective January 1, 2026. The drug is covered only for metastatic colorectal cancer patients as second-line therapy who have failed oxaliplatin-containing regimens or have unresectable metachronous metastases with prior adjuvant chemotherapy, and must be used in combination with irinotecan or FOLFIRI. Claims will be denied without prior authorization and for patients who progress while on Zaltrap.
Medium impact
ZTlido® (lidocaine topical system) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has revised its prior authorization policy for ZTlido (lidocaine 1.8% topical system) effective January 1, 2026, with updates as of May 27, 2026. The policy requires prior authorization for three indications: post-herpetic neuralgia, chronic back pain, and hip/knee osteoarthritis pain. A critical requirement is that all members must have previous treatment with generic lidocaine 5% patch before ZTlido coverage is approved. This is a pharmacy-level prior authorization requirement.
Medium impact
Yutrepia™ (treprostinil) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has issued a revised prior authorization policy for Yutrepia (treprostinil) effective January 1, 2026, with updates as of May 27, 2026. The policy establishes strict prior authorization requirements for two indications: Pulmonary Arterial Hypertension (PAH) requiring prior therapy/intolerance to two drug classes plus a third agent, and Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD) requiring prior Tyvaso DPI therapy. Billing teams must verify all criteria are met and documented before authorization.
Medium impact
Yonsa (abiraterone acetate) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage revised its Yonsa (abiraterone acetate) prior authorization policy effective January 1, 2026, with updates as of May 27, 2026. The policy now requires prior authorization for Yonsa tablet coverage for metastatic castration-resistant prostate cancer (mCRPC) when used in combination with methylprednisolone, and adds a new exclusion criterion denying approval for members who have experienced disease progression while on Yonsa. Billing teams must verify all three approval criteria are met before claims submission and flag any prior therapy history with generic abiraterone acetate.
Medium impact
Yondelis® (trabectedin) (Revised)
Humana·Effective Jan 1, 2026
Humana Indiana Medicaid has revised its prior authorization policy for Yondelis® (trabectedin), an intravenous chemotherapy agent for soft tissue sarcomas and liposarcoma/leiomyosarcoma. The policy establishes specific clinical criteria for approval, including diagnosis requirements and prior treatment history (anthracycline exposure for liposarcoma/leiomyosarcoma cases), with disease progression on Yondelis as an exclusion criterion. Billing teams must implement prior authorization requirements for all Yondelis infusions under this plan effective immediately.
Medium impact
Yondelis® (trabectedin) (Revised)
Humana·Effective Jan 1, 2026
Humana Louisiana Medicaid has revised its prior authorization policy for Yondelis® (trabectedin), an intravenous chemotherapy agent for soft tissue sarcomas. The policy maintains two distinct approval pathways: one for soft tissue sarcoma (including angiosarcoma, rhabdomyosarcoma, and stage IV disease) as monotherapy for palliative treatment, and another for liposarcoma/leiomyosarcoma requiring prior anthracycline therapy. Both pathways exclude members experiencing disease progression on Yondelis. This revised version (effective January 1, 2026, revised June 24, 2026) requires prior authorization before dispensing.
Medium impact
Yondelis® (trabectedin) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicaid Ohio updated the Yondelis (trabectedin) prior authorization policy effective January 1, 2026, with a revision date of June 24, 2026. The policy establishes specific clinical criteria for coverage of this intravenous chemotherapy drug for soft tissue sarcomas, liposarcomas, and leiomyosarcomas. Billing teams must ensure all Yondelis claims for Ohio Medicaid members undergo prior authorization review before dispensing.
Medium impact
Xtandi (enzalutamide) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has revised its Xtandi (enzalutamide) prior authorization policy effective January 1, 2026, with updates as of May 27, 2026. The policy now covers four prostate cancer indications (metastatic castration-resistant, non-metastatic castration-resistant, metastatic castration-sensitive, and non-metastatic castration-sensitive with high-risk biochemical recurrence) with specific clinical criteria and a blanket exclusion for members who have experienced disease progression while on Xtandi. All Xtandi requests require prior authorization before dispensing.
Medium impact
Xospata® (gilteritinib) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage updated its Xospata® (gilteritinib) prior authorization policy effective January 1, 2026, with a revision dated May 27, 2026. The policy requires prior authorization for this FLT3 inhibitor and mandates four specific approval criteria: AML diagnosis, relapsed/refractory disease, documented FLT3 mutation positive status, and monotherapy use. Billing teams must ensure all Xospata claims include verification of these criteria before submission to avoid denials.
High impact
Xgeva® (denosumab) and biosimiliars (Revised)
Humana·Effective Jan 1, 2026
This revised policy (effective January 1, 2026, revised March 25, 2026) updates prior authorization requirements for Xgeva (denosumab) and seven biosimilars across four indications. Key changes include: (1) expanded biosimilar coverage with step-therapy requirements for Medicare switching to biosimilars, (2) clarified step-therapy exemptions for Medicare Part B continuation therapy within 365 days, and (3) reinforced contraindication of concurrent bisphosphonate use. The policy affects Medicare, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid.
Medium impact
Xeomin® (incobotulinumtoxinA) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicaid (Ohio) has updated its Xeomin (incobotulinumtoxinA) prior authorization policy effective January 1, 2026, with revisions as of June 24, 2026. The policy clarifies coverage to four approved indications (blepharospasm, cervical dystonia, chronic sialorrhea, and upper limb spasticity in adults and select pediatric patients) while explicitly excluding numerous off-label uses and all cosmetic applications. All Xeomin requests require prior authorization before dispensing.
High impact
Xeljanz and Xeljanz XR (tofacitinib)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has implemented a new prior authorization policy for Xeljanz/Xeljanz XR (tofacitinib) effective January 1, 2026. The policy requires prior authorization for five indications (psoriatic arthritis, rheumatoid arthritis, ulcerative colitis, polyarticular juvenile idiopathic arthritis, and ankylosing spondylitis) with mandatory documentation of failed or contraindicated therapy with two specific biologics before approval. Billing teams must update systems to enforce these prior authorization requirements and verify member age/diagnosis criteria before claim submission.
Medium impact
Xdemvy® (lotilaner) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has established a new prior authorization policy for Xdemvy® (lotilaner) ophthalmic solution, effective January 1, 2026 and revised May 27, 2026. The medication requires prior authorization with a single clinical criterion: confirmed diagnosis of Demodex blepharitis. Billing teams must implement prior authorization workflows for this newly covered pharmaceutical.
Medium impact
Xarelto® (rivaroxaban) oral suspension (New)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has implemented a new step therapy policy for Xarelto (rivaroxaban) oral suspension effective January 1, 2026. Coverage requires members to have prior treatment failure, contraindication, or intolerance with Xarelto/rivaroxaban tablets, OR be age 17 or younger. This is a newly established policy (1 day old) that creates a coverage gatekeeping requirement for the oral suspension formulation.
Medium impact
Xalkori (crizotinib) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its Xalkori (crizotinib) prior authorization policy effective January 1, 2026, with updates made February 25, 2026. The policy clarifies coverage criteria for three cancer indications: metastatic/recurrent NSCLC (requiring ALK-positivity, ROS1-positivity, or MET exon 14 mutation with documented medical reason for alternative ALK inhibitors), relapsed/refractory ALK-positive ALCL in patients 1-21 years old, and unresectable/recurrent/refractory ALK-positive IMT in patients over 1 year old. All uses require prior authorization.
Medium impact
Winrevair™ (sotatercept-csrk)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage is implementing a new Prior Authorization policy for Winrevair (sotatercept-csrk), a subcutaneous injection for pulmonary arterial hypertension, effective January 1, 2026. Prior authorization is required for all new prescriptions, with specific clinical criteria that must be met: confirmed PAH diagnosis via right heart catheterization, WHO functional class II-IV symptoms, and stable background PAH therapy (either combination therapy or monotherapy due to intolerance).
Medium impact
Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (New)
Humana·Effective Jan 1, 2026
Humana Florida Medicaid has released a NEW prior authorization policy (effective January 1, 2026) for Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), covering two rare neurological conditions: generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP). Prior authorization is now REQUIRED before dispensing this medication. The policy establishes specific clinical criteria that must be met for coverage approval, including confirmed diagnosis, specialist involvement, and for gMG, documented anti-AChR antibody positivity.
Medium impact
Vtama (tapinarof) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its prior authorization policy for Vtama (tapinarof) effective January 1, 2026, with an update dated May 27, 2026. This policy establishes specific prior authorization requirements for Vtama 1% cream coverage in Medicare Advantage plans for two indications: plaque psoriasis (requiring BSA ≥3% with prior treatment/contraindication/intolerance to topical corticosteroids AND vitamin D products, or face/sensitive area involvement) and atopic dermatitis (requiring moderate-to-severe diagnosis, ≥5% BSA, and prior treatment/intolerance to both topical corticosteroids and calcineurin inhibitors). Billing teams must implement prior authorization verification workflows and ensure prescribers document all required clinical criteria before claim submission.
Medium impact
Votrient (pazopanib) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Votrient (pazopanib) effective January 1, 2026, with updates as of April 22, 2026. The policy outlines coverage criteria for five cancer indications (advanced RCC, soft tissue sarcoma, thyroid carcinoma, epithelial ovarian/fallopian tube/primary peritoneal cancer, and uterine sarcoma), with a universal exclusion: members who experienced disease progression on previous Votrient therapy are not eligible for approval. Billing teams must verify prior authorization requirements before claims submission for these oncology cases.
Medium impact
Vosevi® (sofosbuvir, velpatasvir, and voxilaprevir) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has issued a revised prior authorization policy for Vosevi® (sofosbuvir, velpatasvir, voxilaprevir) effective January 1, 2026, with updates as of June 24, 2026. The policy requires prior authorization for this hepatitis C retreatment medication and specifies three clinical approval criteria: chronic HCV diagnosis, non-cirrhotic or compensated cirrhosis status (Child-Pugh Class A), and prior relapse or contraindication to Epclusa. Initial and renewal approvals are limited to 12 weeks based on disease state and genotype per AASLD guidelines.

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

Zemaira® (alpha-1 proteinase inhibitor) (Revised)

Zelboraf (vemurafenib) (Revised)

Zejula (niraparib) (Revised)

Zaltrap (ziv-aflibercept) (New)

Zaltrap (ziv-aflibercept) (New)

Zaltrap (ziv-aflibercept) (New)

ZTlido® (lidocaine topical system) (Revised)

Yutrepia™ (treprostinil) (Revised)

Yonsa (abiraterone acetate) (Revised)

Yondelis® (trabectedin) (Revised)

Yondelis® (trabectedin) (Revised)

Yondelis® (trabectedin) (Revised)

Xtandi (enzalutamide) (Revised)

Xospata® (gilteritinib) (Revised)

Xgeva® (denosumab) and biosimiliars (Revised)

Xeomin® (incobotulinumtoxinA) (Revised)

Xeljanz and Xeljanz XR (tofacitinib)

Xdemvy® (lotilaner) (Revised)

Xarelto® (rivaroxaban) oral suspension (New)

Xalkori (crizotinib) (Revised)

Winrevair™ (sotatercept-csrk)

Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (New)

Vtama (tapinarof) (Revised)

Votrient (pazopanib) (Revised)

Vosevi® (sofosbuvir, velpatasvir, and voxilaprevir) (Revised)