Medicare AdvantagePrior AuthMedium impact
Ulcerative Colitis Agents (Revised)
Humana·Gastroenterology, Internal Medicine, Family Medicine·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has implemented a new step therapy requirement for ulcerative colitis agents effective January 1, 2025. Patients must have tried and failed or shown intolerance to TWO specific first-line treatments (sulfasalazine, balsalazide, mesalamine enema, basic mesalamine capsules, or rectal suppository) before coverage is approved for brand-name UC medications like Apriso, Delzicol, Lialda, and Pentasa.
Action Required
Immediately: Billing team must update prior authorization processes for ulcerative colitis medications (Apriso, Canasa, Delzicol, Dipentum, Lialda, Pentasa) for Humana Medicare Advantage patients. Providers must document that patients have previously tried and failed or were intolerant to TWO of the required first-line treatments before prescribing covered UC agents. Update EMR templates to capture this step therapy documentation. Claims without proper step therapy documentation will be denied.