Medicare AdvantagePrior AuthMedium impact
CFTR Modulators (New)
Humana·Pulmonology, Pediatrics, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has implemented a new prior authorization policy for CFTR modulator medications (including Trikafta, Alyftrek, Kalydeco, Symdeko, and Orkambi) used to treat cystic fibrosis. All prescriptions require prior auth with specific criteria including CF diagnosis, genetic testing documentation, specialist involvement, and step therapy requirements.
Action Required
Before January 1, 2026: Billing team must update prior authorization procedures for CFTR modulator medications (Trikafta, Alyftrek, Kalydeco, Symdeko, Orkambi) for Humana Medicare Advantage patients. Ensure providers obtain prior auth by documenting: (1) CF diagnosis, (2) CFTR gene mutation testing results, (3) treatment by/consultation with pulmonologist, and (4) trial of Trikafta first before other CFTR modulators. Update EMR templates to include these requirements. Claims will be denied without proper prior authorization.