Medicare AdvantagePrior AuthMedium impact
Daybue™ (trofinetide) (Revised)
Humana·Neurology, Pediatrics, Pharmacy·Medicare Advantage
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana updated its Daybue (trofinetide) pharmacy coverage policy for Medicare Advantage members with Rett Syndrome, effective February 25, 2026. The policy requires prior authorization and confirms four mandatory approval criteria: confirmed Rett Syndrome diagnosis, prescription by a Rett Syndrome-experienced provider (neurologist/pediatric neurologist), laxative discontinuation before treatment, and completed kidney function tests (eGFR ≥30 mL/min/1.73m²). Billing teams must ensure all four criteria are verified before claims processing to prevent denials.
Action Required
By February 25, 2026: Billing and clinical teams must implement the following: (1) Update billing system to require prior authorization for all Daybue claims under Medicare Advantage plans; (2) Create or update PA request templates to verify all four approval criteria before submission—specifically confirming Rett Syndrome diagnosis, provider specialty (neurologist or pediatric neurologist), laxative status, and kidney function test results (eGFR); (3) Brief providers and clinical staff that laxatives must be documented as stopped/decreased before Daybue initiation; (4) Ensure front-desk and pre-authorization staff understand this is a new/revised policy requiring immediate PA processing rather than automatic approval; (5) Do NOT process or bill Daybue claims without documented evidence of all four criteria—claims submitted without prior authorization will be denied by Humana. Contact Humana PAL (www.humana.com/PAL) for specific claim code requirements.