Medicare AdvantagePrior AuthMedium impact
Ztalmy® (ganaxolone) (Revised)
Humana·Neurology, Pediatrics, Pharmacy·Medicare Advantage
Effective date
Jul 27, 2022
We identified it
Jun 25, 2026
Summary
Humana updated its Ztalmy® (ganaxolone) pharmacy coverage policy for Medicare Advantage members with a revision date of March 25, 2026. The policy establishes prior authorization requirements for Ztalmy oral suspension (50 mg/ml) for treating seizures associated with CDKL5 Deficiency Disorder in patients age 2 and older. The single approval criterion requires documentation of a confirmed CDKL5 Deficiency Disorder (CDD) diagnosis, with coverage approved for the full plan year on initial and renewal requests.
Action Required
By March 25, 2026 (revision effective date): Pharmacy billing and prior authorization teams must implement this policy update in Humana Medicare Advantage claim systems. (1) Update pharmacy management software to flag Ztalmy (ganaxolone) oral suspension prescriptions for Medicare Advantage members as requiring prior authorization. (2) Configure system to verify member has documented CDKL5 Deficiency Disorder diagnosis before approval. (3) Set approval duration to full plan year for both initial and renewal requests. (4) Notify prescribing providers (primarily pediatric neurology and neurology practices) that Ztalmy now requires prior auth with Humana MA plans and must include CDKL5 diagnosis documentation with requests. (5) Update internal PA submission templates and documentation requirements to reference this policy. Claims submitted without prior authorization will be denied by Humana Medicare Advantage plans.