CommercialPrior AuthMedium impact
Bowel Prep Agents (Revised)
Humana·Gastroenterology, General Surgery, Internal Medicine +1 more·Commercial
Effective date
May 22, 2024
We identified it
Jun 25, 2026
Summary
Humana has revised its Bowel Prep Agents pharmacy coverage policy (effective January 1, 2022, revised May 22, 2024) to implement step therapy requiring members to have a documented trial, intolerance, or contraindication to Clenpiq before coverage of alternative bowel prep agents (MoviPrep, OsmoPrep, Plenvu, Sutab, Suprep, Suflave, and generic equivalents). This is a step therapy requirement that affects all bowel prep prescriptions for covered members.
Action Required
By June 21, 2024: Billing and clinical staff must implement verification of step therapy requirement before submitting claims for bowel prep agents to Humana commercial plans. (1) Update prior authorization workflows to require documentation that the member has completed a trial of Clenpiq, has documented intolerance to Clenpiq, or has a documented contraindication to Clenpiq before approving alternative bowel prep agents. (2) Instruct providers to obtain and document Clenpiq trial status or medical reason for non-use on all bowel prep prescriptions. (3) Update preauthorization request forms and EMR templates to include required Clenpiq step therapy fields. (4) Configure billing software to flag bowel prep claims for Humana commercial members and require step therapy documentation before submission. (5) Train front desk and authorization staff on the new requirement. Claims submitted without documentation of Clenpiq trial, intolerance, or contraindication will be denied or require additional review, delaying reimbursement.