MedicaidPrior AuthMedium impact
Visudyne® (verteporfin) (Revised)
Humana·LA · Ophthalmology·Medicaid
Effective date
Jan 1, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicaid-Louisiana has revised its Visudyne (verteporfin) prior authorization policy effective January 1, 2024, with the most recent revision dated February 25, 2026. The policy establishes specific prior authorization criteria for three indications: neovascular age-related macular degeneration (requiring prior therapy/contraindication/intolerance to bevacizumab), presumed ocular histoplasmosis, and pathologic myopia. All Visudyne IV therapy now requires prior authorization with approval granted for plan year duration initially and renewals.
Action Required
Before January 1, 2024 (retroactive - apply immediately): Billing team and ophthalmology providers must implement prior authorization requirements for all Visudyne (verteporfin) intravenous injections in the Louisiana Medicaid plan. Specifically: (1) Update billing system to flag all Visudyne claims as requiring prior authorization; (2) Providers must document one of three qualifying diagnoses (neovascular AMD with prior bevacizumab failure/contraindication/intolerance, presumed ocular histoplasmosis, or pathologic myopia) before claim submission; (3) Submit prior authorization requests through Humana's PAL system at www.humana.com/PAL with applicable procedure codes; (4) Obtain approval for plan year duration before administering therapy; (5) Process renewals for ongoing coverage. Claims submitted without prior authorization or missing required clinical documentation will be denied. Contact Humana PAL for specific HCPCS J-code requirements for Visudyne injection billing.