MedicaidPrior AuthMedium impact
Visudyne® (verteporfin) (New)
Humana·IN · Ophthalmology·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicaid Indiana has established a new prior authorization policy for Visudyne (verteporfin) effective May 1, 2026. The policy covers three ophthalmic indications: neovascular age-related macular degeneration (requiring prior bevacizumab failure/contraindication/intolerance), presumed ocular histoplasmosis, and pathologic myopia. All Visudyne IV administrations now require prior authorization approval before treatment.
Action Required
By April 30, 2026: (1) Billing and clinical staff must establish prior authorization submission workflow for all Visudyne (verteporfin) intravenous solution requests for Indiana Medicaid members. (2) Update billing system to flag Visudyne claims requiring prior auth before submission. (3) Ensure ophthalmology providers document: for AMD cases, evidence of prior bevacizumab intravitreal injection therapy failure, contraindication, or intolerance; for presumed ocular histoplasmosis, confirmed diagnosis; for pathologic myopia, confirmed diagnosis. (4) Configure prior auth requests to specify which indication is being treated (AMD, presumed ocular histoplasmosis, or pathologic myopia) and include supporting clinical documentation. (5) Notify all ophthalmology providers who treat Indiana Medicaid members of this new requirement. Claims submitted without prior authorization will be subject to denial. Approval duration is limited to plan year, requiring annual renewal.