MedicaidPrior AuthMedium impact
Visudyne® (verteporfin) (New)
Humana·OH · Ophthalmology·Medicaid
Effective date
May 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Ohio Medicaid has implemented a new prior authorization policy for Visudyne® (verteporfin) effective May 1, 2026. The policy requires prior authorization for three indications: neovascular age-related macular degeneration (with prior bevacizumab therapy/contraindication/intolerance requirement), presumed ocular histoplasmosis, and pathologic myopia. Approvals are limited to plan year duration for both initial and renewal periods.
Action Required
By April 15, 2026: Billing and clinical teams must implement prior authorization requirements for all Visudyne (verteporfin) claims for Humana Ohio Medicaid members. (1) Update billing system to flag Visudyne claims as requiring prior authorization before submission. (2) Providers must document one of three diagnoses (neovascular AMD with prior bevacizumab therapy/contraindication/intolerance, presumed ocular histoplasmosis, or pathologic myopia) in patient records. (3) For AMD cases specifically, ensure documentation of prior bevacizumab therapy, documented contraindication, or documented intolerance before requesting authorization. (4) Train front-desk and clinical staff to verify Humana Ohio Medicaid coverage before scheduling Visudyne procedures. (5) Submit prior authorization requests through Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL with appropriate medical and procedural codes. Claims submitted without prior authorization will be denied. Approvals are granted for plan year duration only; renewal authorization will be required annually.