Medicare AdvantagePrior AuthMedium impact
Actinic Keratosis Agents (Revised)
Humana·Dermatology·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Actinic Keratosis Agents prior authorization policy (effective 1/1/2022, revised 11/26/2025). The policy covers diclofenac topical gel and Klisyri (tirbanibulin) ointment for actinic keratosis treatment, requiring prior authorization. Billing teams must ensure all claims for these agents include documentation that the member has tried, experienced intolerance to, or has contraindications to generic imiquimod 5% cream or topical fluorouracil before requesting approval.
Action Required
Immediately: Billing and clinical teams must implement prior authorization requirements for all claims involving diclofenac topical gel 3% and Klisyri (tirbanibulin 1%) ointment for Medicare Advantage members. Before submitting claims: (1) Verify member has documented diagnosis of actinic keratosis; (2) Obtain evidence of prior trial, documented intolerance, or contraindication to generic imiquimod 5% cream OR topical fluorouracil; (3) Attach supporting documentation to prior authorization request. Update billing system templates to flag these medications for mandatory prior auth review. Train front-desk and billing staff to request this documentation from providers before claim submission. Claims submitted without prior authorization or missing required documentation will be denied. Providers should document all contraindications and trial failures in the medical record to support future authorizations.