Medicare AdvantagePrior AuthMedium impact
Repatha® (evolocumab) (Revised)
Humana·Cardiology, Endocrinology, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana has revised their Medicare Advantage prior authorization policy for Repatha (evolocumab), a PCSK9 inhibitor used for cholesterol management and cardiovascular event prevention. The policy establishes specific criteria for coverage including age requirements, diagnosis confirmation, and mandatory statin therapy trials or documented statin intolerance.
Action Required
By January 1, 2026: Billing team must ensure prior authorization is obtained for all Repatha (evolocumab) prescriptions for Medicare Advantage patients. Providers must document: 1) Appropriate diagnosis (hypercholesterolemia, cardiovascular risk, or homozygous familial hypercholesterolemia), 2) Patient age meets requirements (10+ for hypercholesterolemia conditions, 18+ for cardiovascular prevention), 3) Evidence of maximally tolerated statin therapy failure OR documented statin-associated muscle symptoms. Update encounter forms to include statin trial documentation requirements.