Medicare AdvantagePrior AuthMedium impact
Ridaura® (auranofin) (Revised)
Humana·Rheumatology, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Ridaura (auranofin), a gold-based DMARD for rheumatoid arthritis. The policy requires members to have documented failure or intolerance to both an NSAID and a conventional DMARD before coverage is approved. The revision date of January 28, 2026 indicates this is a very recent update requiring immediate implementation.
Action Required
Immediately: Billing team must implement prior authorization requirements for all Ridaura (auranofin) prescriptions for Humana Medicare Advantage members. Before processing any claims: (1) Verify member meets BOTH criteria: diagnosis of rheumatoid arthritis AND prior therapy/contraindication/intolerance with an NSAID (e.g., meloxicam, celecoxib) AND a conventional DMARD (e.g., methotrexate, leflunomide, sulfasalazine); (2) Obtain prior authorization before dispensing; (3) Document all required criteria in member's medical record before submission. Update pharmacy systems and prior auth submission workflows to flag Ridaura for mandatory PA review. Communicate this requirement to all contracted rheumatology providers and pharmacies. Claims submitted without documented prior authorization approval will be denied. Approval is granted in plan year durations or through clinical review.