Medicare AdvantagePrior AuthMedium impact
Zymfentra (infliximab-dyyb) (Revised)
Humana·Gastroenterology, Internal Medicine, General Practice·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 Zymfentra (infliximab-dyyb) effective January 1, 2025. The policy requires prior authorization for both ulcerative colitis and Crohn's disease indications, with approval contingent on patients having either failed/been intolerant to TWO specific biologic therapies (adalimumab products, ustekinumab products, Skyrizi, Rinvoq, or Tremfya) OR completed induction with IV infliximab. Billing teams must verify prior authorization status before claims submission to avoid denials.
Action Required
By January 1, 2025: Billing and authorization teams must implement prior authorization requirements for all Zymfentra (infliximab-dyyb) subcutaneous pen kit and syringe kit claims under Humana Medicare Advantage plans. Before submitting claims: (1) Verify the patient meets diagnostic criteria (moderately to severely active ulcerative colitis or Crohn's disease), (2) Confirm documented prior therapy/contraindication/intolerance with at least TWO of the specified biologic agents OR completed IV infliximab induction doses, (3) Obtain and attach prior authorization approval to all claim submissions. Update billing system workflows to flag Zymfentra claims as requiring prior authorization. Communicate requirements to all providers and clinical staff. Claims submitted without prior authorization approval will be denied. Reference www.humana.com/PAL for specific medical claim coding and preauthorization procedures.