Medicare AdvantagePrior AuthMedium impact
Voquezna® (vonoprazan) (Revised)
Humana·Gastroenterology, Internal Medicine, Family Medicine·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has issued a revised prior authorization policy for Voquezna (vonoprazan) effective January 1, 2025, with updates as of August 27, 2025. The policy establishes specific prior auth requirements for three indications: erosive esophagitis (requires 8-week PPI trial failure + endoscopy confirmation + gastroenterologist involvement), H. pylori infection (requires positive test + combination antibiotic therapy + Talicia failure/contraindication), and non-erosive GERD (requires 4-week max duration + documented PPI intolerance/contraindication to two agents + frequent heartburn). All prescriptions require prior authorization before dispensing.
Action Required
By January 1, 2025: Billing and clinical teams must implement prior authorization requirements for all Voquezna (vonoprazan) prescriptions under Humana Medicare Advantage plans. (1) Update billing system to flag all Voquezna claims for mandatory prior auth submission before dispensing. (2) Create or update provider order entry templates to include required documentation fields: erosive esophagitis cases must document 8-week PPI trial results, endoscopy confirmation date, and gastroenterologist involvement; H. pylori cases must document positive test results and Talicia status; non-erosive GERD cases must document PPI intolerance/contraindication to at least two specific agents and heartburn frequency (4+ days/week). (3) Brief all providers and clinical staff on the three distinct approval pathways and their specific documentation requirements to avoid claim denials. (4) Establish internal tracking to monitor Voquezna continuation therapy (8-month lifetime maximum for erosive esophagitis; 4-week maximum for non-erosive GERD). (5) Implement denial/appeal protocols for claims submitted without required prior authorization or incomplete documentation. Failure to obtain prior authorization will result in claim denials and patient balance issues. Reference Humana's PAL portal at www.humana.com/PAL for claim submission procedures.