Medicare AdvantagePrior AuthMedium impact
Tavneos™ (avacopan) (Revised)
Humana·Rheumatology, Internal Medicine·Medicare Advantage
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana updated its Tavneos (avacopan) prior authorization policy for Medicare Advantage members on December 17, 2025. The policy maintains strict coverage criteria requiring diagnosis of GPA or MPA, positive ANCA testing, severe disease manifestations, specialist prescribing, and combination therapy. For renewals, members must demonstrate positive clinical response with disease stabilization or absence of progression.
Action Required
By December 17, 2025: Billing and prior authorization teams must update internal systems and staff protocols to reflect the revised Tavneos prior authorization requirements for Medicare Advantage members. Verify that all six initial approval criteria are documented and verified before claim submission: (1) member age 18+, (2) GPA or MPA diagnosis, (3) positive PR3 or MPO test, (4) severe disease with life/organ-threatening manifestations, (5) rheumatologist or specialist prescriber, and (6) concurrent standard AAV therapy. For renewal requests, ensure documentation of positive clinical response and disease stabilization is attached. Train prior authorization staff on the renewal criteria changes, particularly the updated list of acceptable maintenance therapies (rituximab, azathioprine, methotrexate, mycophenolate mofetil). Update encounter templates and checklists to prompt providers for all required criteria documentation. Claims submitted without complete documentation of all six criteria will be denied. Note: Avacopan requires hepatitis B and liver function screening before treatment initiation per product warnings.