Medicare AdvantagePrior AuthMedium impact
Statin Products (Revised)
Humana·Cardiology, Internal Medicine, Family Medicine +3 more·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Statin Products step therapy policy (effective 1/1/2022, revised 11/26/2025). The policy now requires members to have BOTH previous treatment with ezetimibe AND previous treatment with one of five specific statins (simvastatin, pravastatin, lovastatin, atorvastatin, or rosuvastatin) before coverage is approved for the listed statin products. This is a step therapy requirement affecting pharmacy claims for multiple statin formulations.
Action Required
IMMEDIATE: Billing and pharmacy teams must update prior authorization workflows in all systems handling Humana Medicare Advantage statin claims. Before processing ANY authorization requests for Lescol XL, fluvastatin (generic/ER), Altoprev, FloLipid, Ezallor Sprinkle, AtorvaliQ, or ezetimibe-rosuvastatin tablets: (1) Verify member has documented prior treatment history with ezetimibe in records; (2) Verify member has documented prior treatment with at least one of: simvastatin, pravastatin, lovastatin, atorvastatin, or rosuvastatin; (3) Update PA request templates to require both criteria before submission to Humana. If either criterion cannot be documented, the claim will be denied under step therapy. Coordinate with prescribing providers to obtain complete medication history. Update internal policies and staff training immediately, as this policy revision date is 11/26/2025 (very recent). Note: The policy effective date is 1/1/2022, but the revision was just released; verify this is not a retroactive requirement change by contacting Humana's PAL department at www.humana.com/PAL.