Medicare AdvantagePrior AuthMedium impact
Caplyta (lumateperone) (Revised)
Humana·Psychiatry, Neurology·Medicare Advantage
Effective date
Jul 24, 2024
We identified it
Jun 24, 2026
Summary
Humana revised its prior authorization policy for Caplyta (lumateperone) effective July 24, 2024, for both Medicare Advantage and Commercial plans. The policy maintains strict prior authorization requirements for treating schizophrenia and bipolar depression, requiring documentation of failed trials with multiple first-line medications before approval.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for all Caplyta prescriptions before dispensing. Verify patient meets age requirements (18+), has appropriate diagnosis (schizophrenia or bipolar I/II disorder), and has documented failures/contraindications to required first-line medications. For schizophrenia: document trials of at least 2 of these medications (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, lurasidone). For bipolar depression: document trial of quetiapine plus at least one other (olanzapine or lurasidone). Claims will be denied without proper prior authorization.