CommercialPrior AuthMedium impact
Vancomycin (Revised)
Humana·Infectious Disease, Gastroenterology, Critical Care +1 more·Commercial
Effective date
Jun 26, 2024
We identified it
Jun 25, 2026
Summary
Humana updated its vancomycin prior authorization policy effective June 26, 2024. The policy maintains coverage for vancomycin (oral and IV formulations) limited to two specific indications: Clostridioides difficile-associated diarrhea and enterocolitis caused by Staphylococcus aureus. Prior authorization is required for all vancomycin products, with approval duration determined by plan year or clinical review.
Action Required
By June 26, 2024: Billing team and providers must ensure all vancomycin prescriptions (capsules, oral solutions, and IV solutions) receive prior authorization from Humana before dispensing or administration. Update EMR/EHR systems and billing software to flag vancomycin orders for prior auth requirement. Verify member diagnosis is documented as either Clostridioides difficile-associated diarrhea OR enterocolitis caused by Staphylococcus aureus (MRSA-inclusive). Communicate to prescribers that oral vancomycin is only approved for these two indications and that IV vancomycin is not effective for these conditions. Claims submitted without prior authorization or for non-covered indications will be denied. Verify current policy version at http://apps.humana.com/tad/tad_new/home.aspx before submitting requests.