All Insurance Policy Changes (Page 77)

Continuing from page 76. 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
Gattex® (teduglutide) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Gattex® (teduglutide) prior authorization policy effective July 22, 2026 for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains coverage for Short Bowel Syndrome patients dependent on parenteral support, with streamlined renewal criteria requiring documented decreases in parenteral support volume. Initial and renewal approvals remain 3 months each.
Medium impact
Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)
Humana·Effective Jan 1, 2019
This is a recent revision (July 22, 2026) to Humana's Erwinase prior authorization policy for Medicaid members in Florida, Kentucky, and South Carolina. The policy establishes strict prior authorization requirements for Erwinase use in acute lymphoblastic leukemia (ALL) patients, requiring documented Grade 2-4 hypersensitivity to prior pegaspargase treatment and excluding patients with serious pancreatitis, thrombosis, hemorrhage, or disease progression history on asparaginase therapy.
Medium impact
Bavencio® (avelumab) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Bavencio (avelumab) prior authorization policy effective July 22, 2026, affecting coverage for renal cell carcinoma, Merkel cell carcinoma (adults and pediatrics age 12+), and urothelial cancer across Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy maintains prior authorization requirements with specific clinical criteria and exclusions for each indication. Billing teams must verify member eligibility against the updated criteria and ensure prior authorization is obtained before claims submission.
High impact
Drug Management Program-Opioid Program (Revised)
Humana·Effective Jul 22, 2026
Humana has revised its Drug Management Program-Opioid Program (effective July 22, 2026) to implement beneficiary-level pharmacy point-of-sale edits for Medicare members at risk of opioid/benzodiazepine abuse. The policy establishes clinical criteria triggering reviews (e.g., ≥90 MME daily average plus multiple prescribers/pharmacies), allows restrictions on MME limits, prescribers, and pharmacies, and includes exclusions for cancer pain, hospice, and palliative care. Billing teams must understand these edits may cause claim denials or rejections if members are flagged and limitations are applied.
Medium impact
Asparlas™ (calaspargase pegol-mknl) (Revised)
Humana·Effective Jul 22, 2026
This is a revised Humana prior authorization policy for Asparlas (calaspargase pegol-mknl) effective July 22, 2026. The policy covers this pegylated L-asparaginase as a component of multi-agent chemotherapy regimens for acute lymphoblastic leukemia (ALL) in pediatric and young adult patients ≤21 years old. Prior authorization is required, with initial and renewal approvals valid for 6 months. Key exclusions include disease progression on prior Asparlas, history of serious thrombosis, pancreatitis, hemorrhagic events, or severely elevated bilirubin.
Medium impact
Oral Acne Antibiotics (Revised)
Humana·Effective Jan 1, 2020
This is a Step Therapy policy for oral acne antibiotics (minocycline extended-release formulations, Solodyn, Seysara, and Ximino) under Medicare Advantage. Members must have previous treatment or documented intolerance with generic immediate-release minocycline before authorization for extended-release formulations. The policy was revised on July 22, 2026, with no changes to the core step therapy requirement.
Medium impact
Mupirocin Topical Cream (Revised)
Humana·Effective Jan 1, 2020
This is a Step Therapy policy for Mupirocin Topical Cream (2% cream formulation) under Medicare Advantage, requiring members to have previous treatment with mupirocin topical ointment within the past 12 months OR documented intolerance before cream approval. The policy was revised on July 22, 2026 (2 weeks old) and establishes coverage criteria for impetigo and other skin/soft tissue infections caused by susceptible Staphylococcus aureus or Streptococcus pyogenes.
Medium impact
Jevtana® (cabazitaxel) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Jevtana (cabazitaxel) prior authorization policy effective January 1, 2020, with the most recent revision dated July 22, 2026. The policy applies to Medicaid programs in Florida, Kentucky, South Carolina, and Virginia, requiring prior authorization for cabazitaxel use in hormone-refractory metastatic prostate cancer patients who meet specific clinical criteria including prior docetaxel treatment and concurrent corticosteroid use. Key exclusions prohibit use in patients with neutrophil counts ≤1,500/mm³, severe hepatic impairment (total bilirubin >3x ULN), or concurrent use with abiraterone acetate or enzalutamide.
Medium impact
Blincyto® (blinatumomab) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Blincyto (blinatumomab) pharmacy coverage policy for Humana Medicare and Medicaid (Kentucky and South Carolina) that maintains prior authorization requirements for three B-cell acute lymphoblastic leukemia (ALL) indications: relapsed/refractory disease, MRD-positive disease in remission, and consolidation phase treatment. The policy was last revised on July 22, 2026 (2 weeks ago) and includes black box warnings for cytokine release syndrome and neurological toxicities.
Medium impact
Arikayce® (liposomal amikacin for inhalation) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Medicare Advantage prior authorization policy for Arikayce (liposomal amikacin for inhalation) effective January 1, 2020, with the most recent revision dated July 22, 2026. The policy requires prior authorization for Arikayce use in MAC lung disease patients who have failed standard multi-drug regimens for at least 6 months and have limited treatment alternatives. Billing teams must ensure all Arikayce requests include documented evidence of prior treatment failure, negative sputum culture attempts, and multi-drug combination therapy verification before claim submission.
Low impact
Givlaari® (givosiran) (Revised)
Humana·Effective Mar 18, 2020
This is a revised Humana prior authorization policy for Givlaari® (givosiran) for treating acute hepatic porphyria, effective March 18, 2020 with the most recent revision dated July 22, 2026. The policy requires prior authorization and confirms three clinical criteria: confirmed diagnosis via elevated PBG/ALA or genetic testing, documented symptoms consistent with acute hepatic porphyria, and administration by a healthcare professional. No substantive coverage changes are evident in this revision compared to the original effective date.
Medium impact
Monjuvi® (tafasitamab-cxix) (Revised)
Humana·Effective Oct 14, 2020
This is a revised Monjuvi (tafasitamab-cxix) prior authorization policy effective October 14, 2020, with the most recent revision dated July 22, 2026. The policy clarifies coverage criteria for two indications: (1) relapsed/refractory DLBCL in combination with lenalidomide for up to 12 cycles then as monotherapy for patients ineligible for autologous stem cell transplant, and (2) relapsed/refractory follicular lymphoma in combination with lenalidomide and rituximab with a maximum of 12 cycles total. All requests require prior authorization and must meet specific clinical criteria to avoid denial.
Medium impact
Nplate® (romiplostim) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Nplate (romiplostim) prior authorization policy for Medicaid in South Carolina, effective January 1, 2021, with updates as of July 22, 2026. The policy establishes coverage criteria for three indications: Persistent/Chronic ITP (requiring platelet count <30 or 30-50 with bleeding plus prior corticosteroid/IVIG trial), Chemotherapy-induced Thrombocytopenia (requiring platelet <100 during myelosuppressive chemo with treatment delay/dose reduction risk), and Hematopoietic Syndrome of Acute Radiation Syndrome. Prior authorization is required for all uses, with specific exclusions for MDS-related thrombocytopenia and certain malignancies (AML, high-risk myelodysplasia, stem cell transplant, lymphoma).
Medium impact
Growth Hormone (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Growth Hormone therapy coverage policy (effective July 22, 2026) for Medicare Advantage members, establishing detailed prior authorization requirements for 17 GH products across pediatric and adult indications. The policy specifies strict diagnostic criteria including growth failure measurements, GH stimulation test results, and specific syndrome diagnoses. Omnitrope is designated as the preferred product for both adults and children.
Medium impact
Doxycycline Antibiotics (Revised)
Humana·Effective Jan 1, 2021
This is a step therapy policy for doxycycline antibiotics under Medicare Advantage that requires members to have prior treatment or documented intolerance with oral immediate-release doxycycline before approval for brand-name or delayed-release formulations. The policy, revised July 22, 2026, applies to multiple doxycycline products including Doryx, Oracea, Avidoxy, and generics used for infections, acne, and rosacea.
Low impact
Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Medicare Advantage prior authorization policy for bexarotene products (Targretin and generic bexarotene) used to treat cutaneous T-cell lymphoma (CTCL). The policy requires prior auth for both oral capsules and topical gel formulations, with approval contingent on disease progression/intolerance to prior therapy or primary treatment use. Pregnancy is an absolute exclusion due to black box warning (FDA Category X).
Medium impact
Acitretin (Revised)
Humana·Effective Jan 1, 2021
This is a revised Humana Medicare Advantage prior authorization policy for acitretin (a retinoid medication) used to treat severe psoriasis. The policy requires prior authorization and mandates that patients meet two criteria: diagnosis of severe cutaneous psoriasis AND previous treatment failure or contraindication to methotrexate or cyclosporine. The policy also includes critical safety warnings regarding teratogenicity, hepatic/renal contraindications, and psychiatric risks.
Medium impact
Gimoti (metoclopramide) (Revised)
Humana·Effective Jul 22, 2026
Humana Medicare Advantage revised its Gimoti (metoclopramide nasal spray) pharmacy coverage policy effective July 22, 2026. The policy requires prior authorization for Gimoti in Medicare Advantage members with diabetic gastroparesis who have failed or are intolerant to generic metoclopramide. Key exclusion: members with a history of tardive dyskinesia or dystonic reaction to metoclopramide are not eligible. The policy emphasizes the black box warning regarding tardive dyskinesia risk and limits treatment duration to 12 weeks unless longer-term use is unavoidable with monitoring.
Medium impact
Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Mircera (methoxy polyethylene glycol-epoetin beta) prior authorization policy for Medicaid in South Carolina and Virginia, effective January 1, 2022, with a revision date of July 22, 2026. The policy requires prior authorization for Mircera use in anemia of chronic kidney disease and establishes specific clinical criteria for initial approval (hemoglobin <10 g/dL, iron studies, exclusion of other anemia causes) and renewal (hemoglobin <11 g/dL or documented dose adjustment). The policy emphasizes the black box warning regarding cardiovascular risks and reinforces that targeting hemoglobin >11 g/dL is not recommended.
Medium impact
Kuvan® (sapropterin) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for Kuvan® (sapropterin) and its generics/brand equivalents used to treat phenylketonuria (PKU). The policy requires prior authorization and specifies that brand Kuvan requests require documentation of previous treatment, contraindication, or intolerance to generic sapropterin. The revision date of July 22, 2026 indicates recent updates to this existing policy.
Medium impact
Isatuximab-irfc Products (Sarclisa, Sarclisa Escena) (Revised)
Humana·Effective May 27, 2026
Humana revised its prior authorization policy for Isatuximab-irfc (Sarclisa, Sarclisa Escena) effective May 27, 2026, covering three multiple myeloma indications across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy maintains prior authorization requirements with specific combination therapy criteria and excludes patients with prior anti-CD38 inhibitor disease progression. Approval duration remains 6 months for initial and renewal periods.
Medium impact
Fetzima® (levomilnacipran) (Revised)
Humana·Effective Jul 22, 2026
Humana Medicare Advantage has revised its prior authorization policy for Fetzima® (levomilnacipran) effective July 22, 2026. The policy requires prior authorization for all Fetzima use in Medicare Advantage members and mandates documentation of prior therapy, intolerance, or contraindication to SNRIs (duloxetine, venlafaxine, desvenlafaxine ER) AND either generic bupropion or mirtazapine before approval for major depressive disorder treatment.
Medium impact
Dihydroergotamine Products (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Dihydroergotamine Products prior authorization policy (effective January 1, 2022, revised July 22, 2026). The policy requires prior authorization for dihydroergotamine injection and nasal spray when used for acute migraine treatment. Patients must meet two criteria: use for moderate to severe migraine headaches and documented previous treatment, intolerance, or contraindication to at least TWO of the following agents (naproxen, naratriptan, rizatriptan, or sumatriptan). Approval is granted for the plan year duration with annual renewal.
Medium impact
Kimmtrak (tebentafusp-tebn) (Revised)
Humana·Effective Jul 22, 2026
Humana has revised its prior authorization policy for Kimmtrak (tebentafusp-tebn), a rare cancer immunotherapy for metastatic uveal melanoma. The policy requires prior authorization and mandates three specific clinical criteria: HLA-A*02:01 positive disease confirmation, unresectable/metastatic uveal melanoma diagnosis, and monotherapy use only. Members with disease progression on Kimmtrak are excluded from coverage.
Medium impact
Evenity® (romosozumab-aqqg) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana prior authorization policy for Evenity (romosozumab-aqqg) for treatment of osteoporosis in postmenopausal women. Key updates include clarified step therapy requirements that differ by plan type: Medicare Part D requires failure/intolerance of TWO specific therapies, Medicare Part B waives step therapy for VERY HIGH RISK patients or continuation therapy within 365 days, and Medicaid requests have NO step therapy requirements. The policy maintains a black box warning exclusion for myocardial infarction or stroke within the preceding year and limits coverage to maximum 12 monthly doses.

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

Insurance Policy Changes Tracker: All Payer Updates (Page 77) | PolicyChanges.app

Gattex® (teduglutide) (Revised)

Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)

Bavencio® (avelumab) (Revised)

Drug Management Program-Opioid Program (Revised)

Asparlas™ (calaspargase pegol-mknl) (Revised)

Oral Acne Antibiotics (Revised)

Mupirocin Topical Cream (Revised)

Jevtana® (cabazitaxel) (Revised)

Blincyto® (blinatumomab) (Revised)

Arikayce® (liposomal amikacin for inhalation) (Revised)

Givlaari® (givosiran) (Revised)

Monjuvi® (tafasitamab-cxix) (Revised)

Nplate® (romiplostim) (Revised)

Growth Hormone (Revised)

Doxycycline Antibiotics (Revised)

Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)

Acitretin (Revised)

Gimoti (metoclopramide) (Revised)

Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)

Kuvan® (sapropterin) (Revised)

Isatuximab-irfc Products (Sarclisa, Sarclisa Escena) (Revised)

Fetzima® (levomilnacipran) (Revised)

Dihydroergotamine Products (Revised)

Kimmtrak (tebentafusp-tebn) (Revised)

Evenity® (romosozumab-aqqg) (Revised)