Medicare AdvantagePrior AuthMedium impact
Ocaliva® (obeticholic acid) (Revised)
Humana·Gastroenterology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2024
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has established a revised prior authorization policy for Ocaliva (obeticholic acid) tablets effective January 1, 2024, requiring specific diagnostic criteria for primary biliary cholangitis patients. The policy includes strict eligibility requirements including documented PBC diagnosis, cirrhosis status verification, and evidence of ursodiol intolerance or inadequate response.
Action Required
Immediately: Billing team must implement prior authorization requirements for all Ocaliva (obeticholic acid) prescriptions for Humana Medicare Advantage patients. Providers must document all five criteria including PBC diagnosis with two confirmatory tests, cirrhosis status assessment, absence of biliary obstruction, no history of decompensated cirrhosis, and either ursodiol intolerance or inadequate response. Update EMR templates to include required documentation checklist. Claims will be denied without proper prior authorization approval.