Medicare AdvantagePrior AuthMedium impact
Jynarque® (tolvaptan) (Revised)
Humana·Nephrology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Jynarque® (tolvaptan) for treating autosomal dominant polycystic kidney disease (ADPKD). The policy requires prior authorization for coverage and mandates that patients meet four specific criteria: ADPKD diagnosis, risk of rapidly progressive disease, CKD stage 2-4, and medication use to slow kidney function decline. The policy includes a black box warning regarding serious liver injury risk and requires mandatory liver function monitoring before treatment initiation and ongoing throughout therapy.
Action Required
By February 25, 2026 (revision date): Billing team must implement prior authorization requirements for all Jynarque® (tolvaptan) claims submitted for Medicare Advantage members. Update billing software and claims submission systems to require prior auth verification before claim processing. Create or update internal documentation checklist to verify all four approval criteria are met before submission: (1) ADPKD diagnosis documentation, (2) evidence of rapidly progressive disease risk, (3) CKD stage 2-4 confirmation, and (4) documentation that medication is being used to slow kidney decline. Notify providers that claims without prior authorization will be denied. Flag for provider review: patients with contraindications including liver disease history, concurrent CYP 3A inhibitors, abnormal sodium levels, inability to sense thirst, hypovolemia, or urinary outflow obstruction—these will not be approved. Ensure prior auth requests include baseline transaminase and bilirubin levels, as monitoring is mandatory per REMS program requirements.