All Insurance Policy Changes (Page 183)

Continuing from page 182. 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
Tobramycin for Inhalation (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage now requires prior authorization for all tobramycin inhalation products (Tobi, Kitabis, Bethkis, Tobi Podhaler) used to treat cystic fibrosis or bronchiectasis with Pseudomonas aeruginosa colonization. Brand name products require additional documentation showing prior therapy with or intolerance to generic tobramycin.
Medium impact
Tivdak (tisotumab vedotin-tftv) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicaid Louisiana has revised their prior authorization policy for Tivdak (tisotumab vedotin-tftv), a cancer drug for recurrent/metastatic cervical cancer. The policy establishes specific criteria including disease progression after chemotherapy and requires that Keytruda cannot be used if CPS score is ≥1.
Low impact
Thymoglobulin (antithymocyte globulin [rabbit]) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has revised its prior authorization policy for Thymoglobulin (antithymocyte globulin rabbit) used for renal transplant rejection. The policy requires strict criteria including confirmed renal transplant, specific indication for prophylaxis or treatment of acute rejection, combination with conventional therapy, and excludes patients with rabbit protein allergies or active infections.
Medium impact
Tasmar® (tolcapone) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage now requires prior authorization for Tasmar (tolcapone) prescriptions for Parkinson's disease patients. Five specific criteria must be met including current levodopa/carbidopa use, failed trial of entacapone plus one other adjunct therapy, and baseline liver function tests.
Medium impact
Tagrisso (osimertinib) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has revised their prior authorization policy for Tagrisso (osimertinib), a cancer medication used to treat non-small cell lung cancer. The policy now covers three specific indications: metastatic NSCLC, adjuvant therapy, and locally advanced unresectable Stage III NSCLC, each with detailed genetic mutation requirements and exclusion criteria.
Medium impact
Symproic® (naldemedine) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage revised their prior authorization policy for Symproic® (naldemedine) for opioid-induced constipation. The policy now requires patients to have failed or have contraindications to both lubiprostone AND Movantik before approval, plus meet specific diagnosis and treatment duration criteria.
Medium impact
Susvimo® (ranibizumab) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicaid Louisiana has updated prior authorization requirements for Susvimo (ranibizumab) intravitreal injections for treating wet AMD, diabetic macular edema, and diabetic retinopathy. All patients must have failed or be intolerant to bevacizumab and have received at least 2 prior VEGF inhibitor injections before approval.
Medium impact
Spinraza® (nusinersen) (Revised)
Humana·Effective Jan 1, 2024
Humana has revised its prior authorization policy for Spinraza (nusinersen) for treating Spinal Muscular Atrophy, effective January 1, 2024. The policy establishes 8 specific criteria for initial approval and 2 renewal criteria, requiring specialist management and prohibiting combination with other SMN2 directed therapies.
Medium impact
Soliris® (eculizumab) (Revised)
Humana·Effective Jul 24, 2024
Humana revised their prior authorization policy for Soliris (eculizumab) effective July 24, 2024, affecting Medicaid Kentucky plans. This is a high-priority update for practices treating rare blood disorders, myasthenia gravis, and neurological conditions requiring this specialty medication.
Medium impact
Signifor® LAR (pasireotide) (Revised)
Humana·Effective Jan 1, 2024
This policy establishes prior authorization requirements for Signifor LAR (pasireotide) injections for treating Cushing's Disease and Acromegaly. Coverage requires specific diagnostic criteria, failed pituitary surgery or surgery not being an option, and no severe liver impairment.
Medium impact
Sandostatin® S.C., Sandostatin LAR® Depot (octreotide acetate for injection) (Revised)
Humana·Effective Jan 1, 2024
Humana has revised its prior authorization policy for Sandostatin and Sandostatin LAR (octreotide acetate injections) used to treat acromegaly, carcinoid tumors, VIPomas, and severe diarrhea conditions. The policy requires prior authorization for brand Sandostatin subcutaneous with specific clinical criteria that must be met for each indication, though previous treatment requirements don't apply to Medicare Part B requests.
Medium impact
Reyvow™ (lasmiditan) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage now requires prior authorization for Reyvow (lasmiditan) for acute migraine treatment, with a new requirement that patients must have previous treatment, intolerance, or contraindication to Ubrelvy before approval. This policy is effective January 1, 2024 with approval duration for the plan year.
Medium impact
Relistor® (methylnaltrexone) (Revised)
Humana·Effective Jan 1, 2024
Humana has updated prior authorization requirements for Relistor® (methylnaltrexone) for opioid-induced constipation treatment. The policy requires failure of specific medications (lubiprostone AND Movantik for chronic non-cancer pain, or lactulose for palliative care patients) before approving Relistor.
Medium impact
Quviviq (daridorexant) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has updated its step therapy policy for Quviviq (daridorexant), an insomnia medication. Members must now have previous treatment, contraindication, or intolerance to Belsomra (suvorexant) or trazodone before Quviviq will be covered.
Medium impact
Prialt® (ziconotide intrathecal infusion) (Revised)
Humana·Effective Jan 1, 2024
Humana has revised their prior authorization policy for Prialt (ziconotide intrathecal infusion) for severe chronic pain management in Medicare patients. The policy maintains strict criteria requiring intolerance to other treatments and excludes patients with psychosis or contraindications to intrathecal therapy.
High impact
Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has updated prior authorization requirements for infliximab products (Remicade, Inflectra, and unbranded infliximab) across multiple conditions including rheumatoid arthritis, Crohn's disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis. The policy includes specific age requirements, prior therapy criteria, and exclusions for combination biologic therapy.
Medium impact
Preferred Infliximab Products - Inflectra (infliximab-dyyb) (Revised)
Humana·Effective Jan 1, 2024
Humana updated their Medicaid prior authorization policy for Inflectra (infliximab-dyyb), a biosimilar to Remicade, establishing specific criteria for approval across multiple conditions including rheumatoid arthritis, Crohn's disease, ulcerative colitis, and other inflammatory conditions. The policy prohibits combination therapy with other biologics and requires prior therapy with conventional treatments before approval.
Medium impact
Preferred Continuous Glucose Monitoring Systems (Revised)
Humana·Effective Jan 1, 2024
Humana has updated its Medicare Advantage prior authorization policy for continuous glucose monitoring systems (CGMs) including Dexcom G6/G7 and FreeStyle Libre devices. The policy requires diabetes diagnosis plus either insulin treatment or documented problematic hypoglycemia for coverage approval.
High impact
Ophthalmic Steroids (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage is implementing new step therapy requirements for ophthalmic steroid medications. Patients must now try two specific generic eye drops (dexamethasone 0.1%, fluorometholone 0.1%, Lotemax SM, prednisolone acetate 1%, or prednisolone sodium phosphate 1%) within the past 12 months before brand-name ophthalmic steroids will be covered.
Medium impact
Ophthalmic Prostaglandins (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage now requires step therapy for specialty ophthalmic prostaglandin eye drops (Zioptan, Xelpros, Travatan Z, tafluprost, Iyuzeh, Zolymbus) used for glaucoma and ocular hypertension. Patients must have tried two specific first-line prostaglandin analogs before these specialty drops will be covered.
Medium impact
Octreotide Products (Revised)
Humana·Effective Jan 1, 2024
Humana revised their octreotide products prior authorization policy for commercial plans, requiring prior treatment or intolerance with generic subcutaneous octreotide before approving brand Sandostatin for acromegaly, carcinoid tumors, and VIPomas. The policy maintains specific diagnosis and symptom criteria for each condition.
Medium impact
Ocaliva® (obeticholic acid) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage has established a revised prior authorization policy for Ocaliva (obeticholic acid) tablets effective January 1, 2024, requiring specific diagnostic criteria for primary biliary cholangitis patients. The policy includes strict eligibility requirements including documented PBC diagnosis, cirrhosis status verification, and evidence of ursodiol intolerance or inadequate response.
Medium impact
Nurtec™ ODT (rimegepant) (Revised)
Humana·Effective Jan 1, 2024
Humana Medicare Advantage updated prior authorization criteria for Nurtec ODT (rimegepant) for migraine treatment. For acute migraines, patients must try Ubrelvy first; for prevention, patients must fail two of three specific migraine preventatives (Aimovig, Emgality, or Qulipta).
High impact
Non-Preferred Infliximab products - Renflexis (infliximab-abda) and Avsola (infliximab-axxq) (Revised)
Humana·Effective Jan 1, 2024
Humana has updated prior authorization requirements for non-preferred infliximab biosimilars Renflexis and Avsola across multiple conditions including rheumatoid arthritis, inflammatory bowel disease, and psoriasis. These drugs now require failure of preferred infliximab products (Remicade, Inflectra, unbranded infliximab) before approval, with additional step therapy requirements for certain conditions.
Medium impact
Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab (Revised)
Humana·Effective Jun 25, 2025
Humana Medicaid Kentucky updated its prior authorization policy for non-preferred infliximab products (Renflexis, Avsola, Remicade, and unbranded infliximab) with a revision date of June 25, 2025. All patients must fail or have intolerance to Inflectra before these non-preferred infliximab products can be approved for various inflammatory conditions including rheumatoid arthritis, Crohn's disease, ulcerative colitis, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis.

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Archive by year

2023 2024 2025 2026

Tobramycin for Inhalation (Revised)

Tivdak (tisotumab vedotin-tftv) (Revised)

Thymoglobulin (antithymocyte globulin [rabbit]) (Revised)

Tasmar® (tolcapone) (Revised)

Tagrisso (osimertinib) (Revised)

Symproic® (naldemedine) (Revised)

Susvimo® (ranibizumab) (Revised)

Spinraza® (nusinersen) (Revised)

Soliris® (eculizumab) (Revised)

Signifor® LAR (pasireotide) (Revised)

Sandostatin® S.C., Sandostatin LAR® Depot (octreotide acetate for injection) (Revised)

Reyvow™ (lasmiditan) (Revised)

Relistor® (methylnaltrexone) (Revised)

Quviviq (daridorexant) (Revised)

Prialt® (ziconotide intrathecal infusion) (Revised)

Preferred Infliximab Products - Remicade (infliximab), Inflectra (infliximab-dyyb), and infliximab (Revised)

Preferred Infliximab Products - Inflectra (infliximab-dyyb) (Revised)

Preferred Continuous Glucose Monitoring Systems (Revised)

Ophthalmic Steroids (Revised)

Ophthalmic Prostaglandins (Revised)

Octreotide Products (Revised)

Ocaliva® (obeticholic acid) (Revised)

Nurtec™ ODT (rimegepant) (Revised)

Non-Preferred Infliximab products - Renflexis (infliximab-abda) and Avsola (infliximab-axxq) (Revised)

Non-Preferred Infliximab Products - Renflexis (infliximab-abda), Avsola (infliximab-axxq), Remicade (infliximab), unbranded Infliximab (Revised)