Medicare AdvantagePrior AuthMedium impact
Xarelto® (rivaroxaban) oral suspension (New)
Humana·Cardiology, Internal Medicine, Hematology +4 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has implemented a new step therapy policy for Xarelto (rivaroxaban) oral suspension effective January 1, 2026. Coverage requires members to have prior treatment failure, contraindication, or intolerance with Xarelto/rivaroxaban tablets, OR be age 17 or younger. This is a newly established policy (1 day old) that creates a coverage gatekeeping requirement for the oral suspension formulation.
Action Required
By December 31, 2025: Billing team and clinical staff must implement the step therapy requirement for Xarelto oral suspension claims. (1) Update prior authorization workflows in billing system to require documentation of: prior Xarelto/rivaroxaban tablet use with failure/contraindication/intolerance, OR patient age 17 or younger. (2) Create or modify PA request templates to capture required eligibility criteria before claim submission. (3) Educate prescribers and clinical staff that oral suspension claims for Medicare Advantage members will be denied without evidence of step therapy criteria being met. (4) Flag all incoming Xarelto oral suspension Rx for Medicare Advantage patients to require PA verification before filling. (5) Do NOT submit claims without PA approval; denials will result from missing step therapy documentation. Coordinate with pharmacy partners to communicate the new requirement.