Medicare AdvantagePrior AuthMedium impact
Winlevi® (clascoterone) (Revised)
Humana·Dermatology, Pediatrics, Family Medicine·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Winlevi® (clascoterone) cream, effective January 1, 2023, with the most recent revision dated February 25, 2026. The policy requires prior authorization for topical clascoterone treatment of acne vulgaris in patients 12+ years old, with mandatory prior failure or contraindication/intolerance to at least two specified topical acne medications. Billing teams must ensure all Winlevi prescriptions include prior authorization before claims are processed.
Action Required
Before submitting any Winlevi® (clascoterone) cream claims: (1) Billing team must verify prior authorization has been obtained before claim submission; (2) Ensure member documentation shows diagnosis of acne vulgaris AND previous treatment failure or contraindication/intolerance with at least TWO of the following: generic tretinoin cream/gel (non-micro formulation), adapalene 0.1% gel, clindamycin lotion/solution/pledgets, erythromycin solution, or clindamycin (1%) and benzoyl peroxide (5%) gel; (3) Update billing system rules to flag Winlevi claims requiring prior authorization status verification; (4) Train front desk and clinical staff to collect documented evidence of prior therapeutic failures before provider prescribes Winlevi; (5) Route all Winlevi prescriptions through the prior authorization workflow using Humana's PAL system at www.humana.com/PAL. Claims submitted without prior authorization will be denied. Note: Tretinoin (non-micro) has additional separate prior authorization requirements that must be verified independently.