Medicare AdvantagePrior AuthMedium impact
Zeposia® (ozanimod) (Revised)
Humana·Neurology, Gastroenterology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana updated its Zeposia (ozanimod) prior authorization policy effective January 1, 2026, with a revision dated May 27, 2026. The policy establishes specific prior authorization requirements for two indications: relapsing forms of multiple sclerosis (requiring failure/inability to use 2+ of 5 specified DMARDs) and moderately to severely active ulcerative colitis (requiring failure/inability to use 2+ of 5 specified biologics). This is a Medicare Advantage pharmacy coverage policy requiring prior authorization before dispensing.
Action Required
By January 1, 2026: (1) Billing and Prior Authorization teams must update the PA submission system to reflect the revised Zeposia prior authorization criteria for both MS and UC indications. (2) For MS patients: Configure system to verify documentation of trial or contraindication to at least TWO of the following: dimethyl fumarate, fingolimod, glatiramer products, Kesimpta (ofatumumab), or teriflunomide before approving Zeposia. (3) For UC patients: Configure system to verify documentation of trial or contraindication to at least TWO of the following: preferred adalimumab products, preferred ustekinumab products, Skyrizi, Rinvoq, or Tremfya before approving Zeposia. (4) Providers submitting Zeposia requests must include documentation of prior medication trials or medical necessity for contraindication on all PA requests. (5) Front-line staff should update authorization request templates to prompt for required prior therapy documentation. (6) Claims for Zeposia submitted without documented evidence of meeting these criteria will be denied. Note: Medical billing requests should reference www.humana.com/PAL for specific coding information.