Medicare AdvantagePrior AuthMedium impact
Viberzi® (eluxadoline) (Revised)
Humana·Gastroenterology, Internal Medicine, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Viberzi® (eluxadoline) prior authorization policy effective January 1, 2026, with a revision dated May 27, 2026. The policy requires prior authorization for Viberzi use in IBS-D patients and mandates documented failure or intolerance to at least TWO specific medications (loperamide, tricyclic antidepressants, or Xifaxan) before approval. Critical exclusions include patients without a gallbladder and those consuming more than 3 alcoholic beverages daily.
Action Required
By January 1, 2026: Billing and clinical teams must implement prior authorization requirements for all Viberzi® prescriptions for Medicare Advantage members. Before submitting claims, verify in patient records that: (1) IBS-D diagnosis is documented, (2) patient has documented treatment failure, contraindication, or intolerance to at least TWO of the following—loperamide, tricyclic antidepressants (amitriptyline, nortriptyline, imipramine, desipramine), or Xifaxan, and (3) patient does not meet exclusion criteria (no prior gallbladder removal, no alcoholism/alcohol abuse, no more than 3 alcoholic beverages per day). Update encounter templates and prior authorization submission forms to include checkboxes for these criteria. Train providers to document medication trials comprehensively. Failure to obtain prior authorization before dispensing will result in claim denials. Contact Humana PAL at www.humana.com/PAL for specific prior authorization submission procedures.