Medicare AdvantagePrior AuthMedium impact
Topical Onychomycotic Agents (Revised)
Humana·Dermatology, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
This is a refreshed Medicare Advantage prior authorization policy for topical onychomycotic agents (Jublia, Kerydin, tavaborole) effective January 1, 2023, with a revision date of February 25, 2026. The policy requires prior authorization for these topical antifungal treatments and mandates that members have a diagnosis of toenail onychomycosis caused by specific Trichophyton species AND documented failure or contraindication to oral antifungal therapy (terbinafine plus at least one of: itraconazole, ciclopirox, or griseofulvin). No new changes to requirements are evident, but billing teams must ensure compliance with these two strict criteria for all pharmacy claims.
Action Required
By March 15, 2026: Billing and prior authorization teams must verify all topical onychomycotic agent claims (Jublia/efinaconazole, Kerydin/tavaborole, tavaborole generic) meet BOTH criteria before submission to Humana Medicare Advantage plans: (1) Member has documented diagnosis of onychomycosis of toenails caused by Trichophyton rubrum or T. mentagrophytes; (2) Member has documented previous treatment, contraindication, or intolerance to oral terbinafine AND at least one of: itraconazole, ciclopirox nail solution, or griseofulvin. Update prior authorization submission templates and internal verification checklists to explicitly require documentation of failed oral antifungal therapy. Train billing staff and providers on the dual-requirement criteria. Flag any claims lacking evidence of prior oral antifungal failure for denial prevention. Contact Humana at PAL portal (www.humana.com/PAL) if requesting medically billed pharmacy coding questions.