Medicare AdvantagePrior AuthMedium impact
Caplyta® (lumateperone) (Revised)
Humana·Psychiatry, Family Medicine, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has implemented new prior authorization requirements for Caplyta (lumateperone) effective January 1, 2025, covering treatment for schizophrenia, bipolar disorder, and major depressive disorder. The policy requires documentation of prior therapy failures with specific alternative medications before approval, with different criteria for each indication.
Action Required
Immediately: Update prior authorization workflows for Caplyta prescriptions for Humana Medicare Advantage patients. Ensure providers document previous treatment failures, intolerances, or contraindications to required alternative medications before prescribing. For schizophrenia: document trials of at least 2 of risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, or lurasidone. For bipolar depression: document quetiapine trial plus one of olanzapine or lurasidone. For MDD: document antidepressant monotherapy trial plus generic atypical antipsychotic adjunct therapy trial. Claims without proper prior authorization will be denied.