We track 50 documented policy changes from Humana across AK, AL, AR, AS, AZ and 5 more states. Each entry includes an AI-generated plain-English summary, effective date, affected billing codes, and a direct link to the original Humana notice. Use the related links below to narrow results by specialty or state, or create a free alert to get new Humana updates by email (daily or weekly, your choice, on every plan).
Effective January 1, 2027, Humana Illinois Medicaid implements a new pharmacy coverage policy limiting initial benzodiazepine dispensing to a maximum 14-day supply for new users (no benzodiazepine claim in past 60 days), with prior authorization required for initial claims exceeding this limit. Subsequent fills after the initial dispensing follow standard renewal guidelines. This policy applies to 15 benzodiazepine medications across all formulations.
Humana has implemented a new prior authorization policy for SGLT2 Inhibitors effective January 1, 2027, affecting Medicare Advantage members. The policy requires prior auth for six SGLT2 inhibitor medications (Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Synjardy, Synjardy XR) and mandates that members have Type 2 diabetes AND have tried or cannot take empagliflozin or dapagliflozin-containing medications before approval.
Effective January 1, 2027, Humana Medicare Advantage is implementing a new prior authorization policy for non-preferred ustekinumab products (Stelara, Imuldosa, Pyzchiva, Selarsdi, Starjemza, Steqeyma, and biosimilars). Providers must now document step-therapy requirements—patients must have tried or be unable to use specific preferred alternatives before non-preferred ustekinumab products can be approved. This is a pharmacy coverage policy requiring prior authorization for four indications: ulcerative colitis, Crohn's disease, chronic plaque psoriasis, and psoriatic arthritis.
Effective January 1, 2027, Humana Medicare Advantage implements a new prior authorization policy for 13 long-acting opioid medications. All long-acting opioid prescriptions now require prior authorization and must meet four strict criteria: persistent non-acute pain requiring around-the-clock treatment, severe enough to warrant opioids, failure/inability to use immediate-release opioids, and failure/inability to use morphine ER or fentanyl patch. This represents a significant tightening of opioid access under Medicare Advantage.
Humana Medicare Advantage has implemented a new prior authorization policy for Jardiance (empagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. All three indications require documented failure or inability to use generic dapagliflozin as a prerequisite, with specific exclusions including eGFR <30 for diabetes glycemic control, polycystic kidney disease for CKD, and certain immunosuppressive therapy use for CKD.
Humana has implemented a NEW prior authorization policy for Januvia (sitagliptin) effective January 1, 2027, for Medicare Advantage members with type 2 diabetes. Coverage requires members to have tried or be unable to use generic sitagliptin first, and prior authorization is mandatory for all brand-name Januvia prescriptions.
Humana Medicare Advantage has implemented a new prior authorization requirement for Janumet (sitagliptin/metformin) effective January 1, 2027. Coverage requires patients to have type 2 diabetes and either tried or be unable to use generic sitagliptin/metformin, with a critical exclusion: patients with a history of pancreatitis are not eligible. This is a brand-to-generic step therapy policy.
Humana Medicare Advantage has implemented a new prior authorization policy for Farxiga (dapagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. The policy requires prior authorization for brand Farxiga when generic dapagliflozin has not been tried or cannot be used, with specific clinical criteria and exclusions for each indication.
Humana Medicare Advantage has implemented a new prior authorization policy for DPP-IV/SGLT2 combination diabetes medications (Steglujan, Qtern, Glyxambi, dapagliflozin-saxagliptin). Effective January 1, 2027, all claims for these products require prior authorization and must meet two criteria: Type 2 Diabetes Mellitus diagnosis AND documented trial or contraindication to a single DPP-4 inhibitor (sitagliptin or linagliptin) OR a single SGLT2 inhibitor (empagliflozin or dapagliflozin). Approvals are granted for plan year durations or as determined through clinical review.
Historical material: Humana's Q4 2026 physician newsletter (published October 1, 2026, first found by PolicyChanges on November 4, 2026) announces prior authorization and notification lists for Medicare Advantage and Dual Eligible Special Needs Plan patients that take effect January 1, 2027, plus Medicaid and Part D medication list changes and immunology biosimilar rules. The newsletter does not list individual codes, so the actual lists must be checked in Humana's PAL search tool; the rest of the newsletter is reminders on documentation, 100-day prescribing and claims payment policies.
Humana is implementing a new prior authorization pharmacy coverage policy for Trijardy XR (a fixed-dose combination of empagliflozin, linagliptin, and metformin) effective January 1, 2027. The policy requires prior authorization for Medicare Advantage members with type 2 diabetes who have tried or cannot take individual DPP-4 inhibitors, SGLT2 inhibitors, and metformin before approval.
Humana Medicare Advantage is implementing a new prior authorization policy for Tremfya (guselkumab) effective January 1, 2027. The policy covers four indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease across multiple formulations (IV and subcutaneous). Billing teams must verify member eligibility against specific clinical criteria (diagnosis, age, weight, prior treatment) before claims submission.
Humana is implementing a new prior authorization policy for tramadol extended-release products (ConZip, tramadol ER capsule, and tramadol ER tablet) effective January 1, 2027. The policy establishes four mandatory approval criteria: persistent non-acute pain requiring around-the-clock treatment, pain severe enough to require opioid medication, failed trials of alternative treatments, and prior trial or inability to tolerate immediate-release tramadol 50mg. Billing teams must implement prior authorization requirements for all tramadol ER prescriptions under Medicare Advantage plans.
Humana Medicare Advantage has implemented a new prior authorization requirement for Janumet XR (sitagliptin/metformin extended-release) effective January 1, 2027. Coverage requires members to have type 2 diabetes AND have tried or be unable to use generic sitagliptin/metformin ER. The policy excludes members with a history of pancreatitis.
Humana has implemented a new prior authorization policy for Epclusa® (sofosbuvir/velpatasvir) effective January 1, 2027, for Medicare Advantage members with chronic hepatitis C. The policy requires prior auth for both brand and generic formulations, with approval duration of 12 weeks or based on AASLD treatment guidelines. Brand Epclusa requires documentation that the member cannot use generic sofosbuvir/velpatasvir.
Humana Medicare Advantage has implemented a new prior authorization policy for Eltrombopag Olamine (Promacta and generics) effective January 1, 2027. The policy requires prior authorization for three indications: persistent/chronic immune thrombocytopenia (ITP), thrombocytopenia in hepatitis C patients, and aplastic anemia. Initial approvals are valid for 6 months, with renewals based on platelet count thresholds (<400 x10⁹/L) and indication-specific clinical criteria.
Humana revised its Medicare Advantage Spinal Decompression Surgery coverage policy (HUM-1216-006), with an effective date of 11/02/2026 and an annual review dated 10/13/2026. The revision updates coverage criteria for discectomy, laminectomy/laminotomy/foraminectomy/foraminotomy, laminoplasty and corpectomy, adds coverage limitations excluding several percutaneous and laser discectomy techniques, annular closure, and AI/augmented-reality-guided decompression, and updates coding information including new 2026 codes 62330, 62331 and 63032.
Humana revised its Medicare Advantage knee arthroscopy coverage policy (HUM-1286-002), with the source stating an effective date of 11/02/2026 and a review date of 10/13/2026. The policy sets criteria for when arthroscopic knee procedures are medically reasonable and necessary, including documented imaging, failed provider-directed conservative management, and specific indications for articular cartilage lesions, diagnostic arthroscopy, meniscal tears, ligament injuries, synovial disease, and others, and it excludes arthroscopy for severe osteoarthritis (Outerbridge Grade III or IV) and needle arthroscopy (29999).
Humana Medicare Advantage revised its Knee Arthroplasty policy effective 11/02/2026, establishing detailed medical necessity criteria for unicompartmental knee arthroplasty (UKA) procedures. The policy requires prior authorization documentation including specific imaging classifications, failure of conservative treatment, BMI-related weight management education for obese patients, preoperative hemoglobin A1C testing, and absence of listed contraindications before UKA procedures will be covered.
Humana revised its Medicare Advantage policy on headache and occipital neuralgia treatments effective 11/02/2026, expanding coverage criteria for occipital nerve stimulation and trigger point injections while maintaining exclusions for certain surgical interventions and specific conditions (neck pain, tension headache, cluster headache). Billing teams must verify applicability of jurisdiction-specific LCDs and update medical necessity criteria in their review processes for affected procedure codes.
Humana Indiana Medicaid has established a new prior authorization policy effective November 1, 2026, for pembrolizumab products (Keytruda intravenous powder, Keytruda intravenous solution, and Keytruda Qlex subcutaneous solution) covering 26 cancer indications. The policy specifies clinical criteria, exclusions (including prior anti-PD-1/PD-L1 therapy), and approval durations of 6 months or as determined through clinical review for each indication. Billing teams must obtain prior authorization before these drugs are dispensed or claims will be denied.
Humana Louisiana Medicaid has established a new prior authorization policy for pembrolizumab products (Keytruda IV powder, Keytruda IV solution, Keytruda Qlex subcutaneous) effective November 1, 2026. The policy covers 26 cancer indications with specific clinical criteria, combination therapy requirements, and exclusions (including disease progression on prior anti-PD-1/PD-L1 therapy). All pembrolizumab claims for these indications require prior authorization before the service is rendered or claims will be denied.
Humana Ohio Medicaid established a new prior authorization policy effective November 1, 2026, for pembrolizumab products (Keytruda intravenous powder, intravenous solution, and Keytruda Qlex subcutaneous solution) across 25 cancer indications. Each indication has specific clinical criteria, required combination or monotherapy regimens, biomarker requirements (CPS, PD-L1, dMMR/MSI-H, or TMB-high scores where applicable), and exclusions based on prior anti-PD-1/PD-L1 therapy. Initial and renewal approvals are granted for 6 months or as determined through clinical review.
This is a revised Medicare Advantage policy on injections for pain conditions (epidural steroid, facet joint, sacroiliac, trigger point, peripheral nerve blocks, and dry needling) effective 11/01/2026. The policy document itself does not contain specific billing code changes, coverage denials, or new requirements—it primarily references applicable MAC Local Coverage Determinations (LCDs) by geographic jurisdiction. Billing teams must ensure claims comply with the specific MAC LCD rules in their region, as Humana applies the MAC's LCD to all requests.
Humana Medicaid Indiana has established a new pharmacy coverage policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective November 1, 2026, covering seven HER2-related cancer indications including early breast cancer, metastatic breast cancer, HER2-low and HER2-ultralow breast cancer, gastric adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors. All uses require prior authorization with specific clinical criteria and treatment cycle limits.
Humana Louisiana Medicaid has established a new prior authorization pharmacy coverage policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective November 1, 2026. The policy covers seven HER2-related cancer indications with specific clinical criteria for approval, including early breast cancer, metastatic breast cancer, HER2-low/ultralow breast cancer, gastric adenocarcinoma, HER2-mutant non-small cell lung cancer, and HER2-positive solid tumors. Billing teams must implement prior authorization requirements for all Enhertu claims under Louisiana Medicaid before the effective date.
Humana's pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Alymsys, Vegzelma, Jobevne) is dated effective 10/28/2026 for Medicare, Medicaid Kentucky, Medicaid South Carolina, and Medicaid Virginia. It sets prior authorization criteria by indication, including a step-therapy requirement that members have an intolerance or contraindication to Mvasi or Zirabev before Avastin, Alymsys, Jobevne, or Vegzelma oncology requests, plus indication-specific diagnosis and regimen requirements. Billing teams should verify these criteria against the current policy version before scheduling affected infusions.
Humana Medicaid–Florida established a new prior authorization policy effective October 28, 2026, for rituximab products (Ruxience, Riabni, Truxima, and generics). The policy covers nine disease categories—including chronic lymphocytic leukemia, immune thrombocytopenic purpura, non-Hodgkin's lymphoma, Hodgkin's lymphoma, rheumatoid arthritis, Waldenstrom's macroglobulinemia, post-transplant lymphoproliferative disorder, vasculitis, and pemphigus vulgaris—plus all other medically accepted uses. Prior authorization is now required before dispensing; claims without it will be denied.
Humana Florida Medicaid has established a new prior authorization policy for bevacizumab products (Mvasi, Zirabev, Vegzelma, Avastin) effective October 28, 2026. The policy covers 13 oncologic and ophthalmologic indications with specific clinical criteria requirements for approval. Billing teams must implement prior authorization requirements before dispensing these drugs to Medicaid members.
Humana has implemented a new Prior Authorization pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) effective immediately. The policy establishes specific clinical criteria and step-therapy requirements for six oncology indications and three ophthalmology indications across Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). Billing staff must verify member eligibility against detailed criteria before processing claims for these drugs.
Humana Medicaid in Michigan has published a new breast procedures coverage policy (HUM-MI-2030-000) effective 2026-10-28 that establishes specific medical necessity criteria for breast lesion excision, breast reconstruction, implant removal/revision, and implant-associated malignancy procedures. The policy defines covered CPT codes and clinical indications (e.g., atypical hyperplasia, fibroadenoma >2.5 cm, capsular contracture Baker III-IV, BIA-ALCL/BIA-SCC) that must be met for claims approval.
Humana Indiana Medicaid revised its breast procedures policy (HUM-IN-2030-002) effective 2026-10-28, establishing updated coverage criteria for breast lesion excision, reconstruction, and implant-related procedures. The policy clarifies eligibility requirements for common procedures like excision (CPT 19120, 19125), reconstruction (CPT 19325, 19342, 19350, 19380), and implant removal/revision (CPT 19328, 19330, 19370, 19371). Billing teams must verify that prior authorizations and claim submissions align with the revised criteria, particularly for cases involving fibroadenoma, atypical hyperplasia, capsular contracture, and breast implant-associated malignancies.
Humana Illinois Medicaid has adopted a new breast procedures coverage policy (HUM-IL-2030-000) effective 2026-10-28, establishing medical necessity criteria for breast lesion excision, breast reconstruction, capsulotomy/capsulectomy, implant removal, and implant reinsertion. The policy specifies eligible diagnoses, surgical procedures, and CPT codes for coverage determination under Illinois Medicaid.
Humana Florida Medicaid revised its Genomic and Molecular Biomarker Testing for Cancer policy (HUM-FL-2248-002), effective 10/21/2026. The policy establishes coverage criteria for single-gene testing (BTK, CEBPA, IDH1/IDH2, MYD88, NPM1, PLCG2), panel testing, liquid biopsy, thyroid molecular markers, and molecular pathology procedures for hematologic and solid organ malignancies. This revision supersedes the original policy effective 08/05/2025.
Humana Kentucky Medicaid has revised its Orthotics coverage policy, effective 2026-10-14. The policy establishes medical necessity criteria, prior authorization requirements, and specific HCPCS codes for coverage of braces, splints, casts, and other orthotic devices across lower extremity, foot, spine, and upper extremity categories. Billing teams must verify prior authorization is obtained before claims submission and ensure documentation supports medical necessity for each orthotic type.
Humana Kentucky Medicaid revised its Orthotics policy (HUM-KY-2177-001), effective 2026-10-14. The policy establishes coverage criteria and prior authorization requirements for orthotics including braces, splints, casts, foot orthotics, spine orthotics, and upper extremity orthotics across multiple HCPCS codes. This is a full policy revision with an original effective date of 2025-06-03 and a new effective date of 2026-10-14.
Humana Kentucky Medicaid has implemented a new coverage policy (HUM-KY-2248-000) for genomic and molecular biomarker testing in cancer patients, effective 10/14/2026. The policy establishes coverage criteria and prior authorization requirements for specific multigene panel tests, single gene tests, liquid biopsies, and other molecular pathology tests used in hematologic malignancies, solid tumors, and thyroid nodule evaluation.
Humana Medicaid Virginia revised its Gene Expression Profiling (GEP) coverage policy effective 2026-10-14, maintaining coverage for specific tests (Cxbladder Triage, ConfirmMDx, and molecular pathology/MAAA tests meeting clinical criteria) while continuing to exclude 19 named GEP tests due to insufficient evidence. Billing teams must verify which GEP tests are ordered against the coverage lists and enforce prior authorization requirements based on clinical criteria.
Humana Healthy Horizons Louisiana Medicaid revised its coverage policy for wheelchairs, wheelchair repairs, standing frames, and patient lifts effective 2026-10-07. The policy clarifies prior authorization requirements, medical necessity criteria, required documentation (including state-licensed physician and therapist evaluations), and coverage limitations. Only one wheelchair at a time is covered; backup chairs are denied. All wheelchairs and modifications require prior authorization.
Humana Kentucky Medicaid has issued a new spinal decompression surgery coverage policy (HUM-KY-2660-000) effective 2026-10-07, establishing medical necessity criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy specifies coverage requirements including diagnostic imaging confirmation, clinical symptoms, and conservative treatment trial periods (6 weeks for herniated disc with radicular pain). Prior authorization is required for all covered services under this policy.
Humana Louisiana Medicaid revised its Applied Behavior Analysis (ABA) coverage policy effective 10/07/2026, establishing a two-step prior authorization process requiring a comprehensive diagnostic evaluation (CDE) by a qualified health care professional before ABA services can be authorized. The policy clarifies QHCP qualifications, CDE requirements, behavior treatment plan documentation, and coordination with IEPs and waiver services for members under 21 with diagnosed behavioral/developmental conditions.
Humana's revised Louisiana Medicaid policy on skin and tissue substitutes covers these products only for partial and full-thickness diabetic lower extremity ulcers that meet a list of criteria, and it requires prior authorization with documentation that every criterion is met. It also limits coverage to 10 treatments in a 12-week period, stops coverage after five applications with no measurable decrease in wound size or depth, and bars using two products at once or hyperbaric oxygen at the same time. The source states an effective date of 10/07/2026, which has already passed, so confirm the policy is still the current version before relying on it.
This is a NEW Humana Louisiana Medicaid policy (effective 10/07/2026) establishing coverage criteria for skin and tissue substitutes limited to partial and full-thickness diabetic lower extremity ulcers only. All other indications are not covered. Coverage requires prior authorization, comprehensive wound care documentation, specific clinical criteria (ulcer ≥1 cm, ≥4 weeks duration, no measurable healing despite therapy), HbA1c ≤9%, adequate circulation, and is capped at 10 treatments per 12 weeks with a hard stop after 5 applications without improvement.
Humana Indiana Medicaid has established a prior authorization policy for Imfinzi (durvalumab) covering nine cancer indications including biliary tract cancer, endometrial cancer, gastric/gastroesophageal junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, and unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy specifies coverage criteria, treatment combinations, exclusions (including prior anti-PD-1/PD-L1 therapy), and approval durations of 6 months per initial or renewal authorization.
Humana Medicare Advantage revised its Peripheral Artery Revascularization of the Lower Extremities policy effective October 1, 2026, establishing specific medical necessity criteria for lower extremity PTA with stenting, atherectomy, and intravascular ultrasound. The policy references applicable Local Coverage Determinations (LCDs) by MAC jurisdiction and outlines coverage for alternative revascularization methods including deep vein arterialization and percutaneous transmural arterial bypass.
Humana Medicaid Ohio is implementing a new prior authorization policy for Nplate (romiplostim) effective October 1, 2026, covering three indications: persistent/chronic immune thrombocytopenia (ITP), chemotherapy-induced thrombocytopenia (CIT), and hematopoietic syndrome of acute radiation syndrome (HS-ARS). Billing teams must obtain prior authorization before dispensing, with specific clinical criteria and platelet count thresholds required for each indication.
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
Humana Medicare Advantage has issued a revised policy (effective 10/01/2026) that declares interspinous process decompression spacers (including Superion/Vertiflex devices) as NOT medically reasonable and necessary. This is a non-coverage determination, meaning claims for CPT 22869, 22870, and HCPCS C1821 will be denied for all Medicare Advantage members. Billing teams must update denial protocols and inform providers immediately.
Humana Medicaid Indiana has released a new pharmacy coverage policy for Imfinzi (durvalumab), effective October 1, 2026. The policy establishes prior authorization requirements for 9 cancer indications with specific clinical criteria and contraindications based on prior anti-PD-1/PD-L1 therapy exposure. Billing teams must implement prior authorization workflows for all Imfinzi claims and verify member eligibility against documented diagnosis, treatment regimen, and exclusion criteria.
Humana Medicaid (Louisiana) has implemented a new prior authorization policy for Imfinzi (durvalumab) effective October 1, 2026, covering 10 oncologic indications including biliary tract cancer, endometrial cancer, gastric/GE junction adenocarcinoma, hepatocellular carcinoma, non-small cell lung cancer (metastatic, perioperative, unresectable), small cell lung cancer (extensive and limited stage), and bladder cancer. The policy requires specific combination chemotherapy regimens and excludes patients with prior disease progression on anti-PD-1/PD-L1 therapies.
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