Medicare AdvantagePrior AuthMedium impact
Vykat XR (diazoxide choline) (Revised)
Humana·Pediatrics, Endocrinology, Genetics·Medicare Advantage
Effective date
Jun 25, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has established a new prior authorization policy for Vykat XR (diazoxide choline) effective June 25, 2025, for treating hyperphagia in Prader-Willi syndrome patients. The policy requires four mandatory approval criteria: PWS diagnosis confirmed by genetic testing showing chromosome 15q11-q13 abnormality, documented hyperphagia symptoms, and prescribing by a PWS specialist. All Vykat XR claims must obtain prior authorization before dispensing.
Action Required
By June 25, 2025: Billing team must implement prior authorization requirement for Vykat XR (diazoxide choline) in billing system. Providers must submit prior authorization requests with: (1) genetic testing documentation confirming PWS diagnosis with chromosome 15q11-q13 abnormality, (2) clinical evidence of hyperphagia, and (3) confirmation that prescriber has PWS treatment expertise. Update encounter forms and billing workflows to flag Vykat XR prescriptions for mandatory prior auth verification before claim submission. Pharmacy team should coordinate with providers on required documentation. Claims submitted without prior authorization approval will be denied by Humana Medicare Advantage.