Medicare AdvantagePrior AuthHigh impact
Vesicare and Vesicare LS (solifenacin) (Revised)
Humana·Urology, Pediatrics, Geriatrics·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its prior authorization policy for Vesicare and Vesicare LS (solifenacin) effective January 1, 2025, with a revision dated February 25, 2026. The policy establishes two distinct approval pathways: one requiring prior failure/contraindication/intolerance with TWO agents (oxybutynin IR/ER, solifenacin, Myrbetriq, or Gemtesa) for overactive bladder, and another requiring prior failure with BOTH oxybutynin AND Myrbetriq OR age under 3 years for neurogenic detrusor overactivity. All Vesicare prescriptions now require prior authorization before dispensing.
Action Required
By January 1, 2025, the billing and clinical team must: (1) Update prior authorization submission processes to require documentation of previous treatment attempts, contraindications, or intolerances meeting the specified criteria before dispensing any Vesicare or Vesicare LS prescription; (2) Create or revise prescription routing workflows to route all solifenacin requests to utilization management for prior auth review; (3) Brief providers and clinical staff on the two distinct criteria pathways (OAB vs. neurogenic detrusor overactivity) to ensure accurate prior auth requests; (4) Update pharmacy benefit system to flag all Vesicare/Vesicare LS claims as requiring prior authorization; (5) Communicate with contracted pharmacies that this is a prior authorization drug effective immediately. Failure to obtain prior authorization will result in claim denials and member out-of-pocket costs. This is a pharmacy policy revision affecting Medicare Advantage members only.