Medicare AdvantagePrior AuthMedium impact
Zepatier® (elbasvir/grazoprevir) (Revised)
Humana·Infectious Disease, Gastroenterology, Internal Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Zepatier® (elbasvir/grazoprevir) prior authorization policy effective January 1, 2026, with a revision date of June 24, 2026. The policy requires prior authorization for chronic hepatitis C treatment (genotypes 1 or 4) with specific clinical criteria: documented HCV diagnosis, genotype confirmation, and prior treatment failure or contraindication to Epclusa. Approval is limited to 12-16 weeks per AASLD guidelines, and patients with moderate-to-severe hepatic impairment (Child-Pugh B or C) are excluded.
Action Required
By January 1, 2026 (or immediately if date has passed): Billing and prior authorization teams must implement the following: (1) Update prior authorization submission requirements in billing system to mandate submission of clinical documentation proving chronic HCV diagnosis, genotype 1 or 4 confirmation, and evidence of prior SVR failure or Epclusa contraindication before claims can be processed; (2) Configure system to flag and deny claims for any patient with documented Child-Pugh B or C hepatic impairment; (3) Set authorization duration limits to 12-16 weeks per AASLD treatment guidelines, requiring reauthorization after initial approval period; (4) Update provider education materials and claim submission guidance to reflect these criteria; (5) Train billing staff to reject incomplete prior authorization requests lacking required genotype and treatment history documentation. Failure to obtain proper prior authorization or missing required clinical documentation will result in claim denials. Reference Humana's PAL system at www.humana.com/PAL for applicable billing codes.