Medicare AdvantagePrior AuthMedium impact
Praluent® (alirocumab) (New)
Humana·Cardiology, Endocrinology, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
New prior authorization policy for Praluent (alirocumab) injections effective January 1, 2026, for Medicare Advantage plans. The policy requires specific criteria including diagnosis, age requirements, statin therapy trials, and previous treatment with Repatha before approving Praluent for hypercholesterolemia, cardiovascular event prevention, or homozygous familial hypercholesterolemia.
Action Required
By January 1, 2026: Billing team must update prior authorization workflows for Praluent (alirocumab) injections for Medicare Advantage patients. Providers must document: 1) Appropriate diagnosis (hypercholesterolemia, cardiovascular risk, or HoFH), 2) Age requirements (8+ for hypercholesterolemia, 18+ for CV prevention and HoFH), 3) Statin therapy trials or intolerance documentation, and 4) Previous Repatha treatment, contraindication, or intolerance. Update EMR templates to capture required criteria. Claims will be denied without proper prior authorization.