Medicare AdvantagePrior AuthMedium impact
Vancomycin capsules (Revised)
Humana·Infectious Disease, Gastroenterology, General Practice +1 more·Medicare Advantage
Effective date
Jun 26, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its vancomycin capsule prior authorization policy effective June 26, 2024. The policy maintains prior authorization requirements for vancomycin capsules (125 mg and 250 mg) when prescribed for Clostridioides difficile-associated diarrhea or Staphylococcus aureus enterocolitis. The revision clarifies that approval duration is determined by plan year or clinical review, with no changes to covered indications or approval criteria from the prior version.
Action Required
By July 15, 2024: Billing team and providers must ensure all vancomycin capsule prescriptions submitted to Humana Medicare Advantage include prior authorization. Update billing system notes to reflect the June 26, 2024 revision date. Verify that claims for vancomycin are only submitted for documented diagnoses of Clostridioides difficile-associated diarrhea or Staphylococcus aureus enterocolitis. Communicate to prescribers that prior auth requests must include diagnosis confirmation. Claims submitted without prior authorization or for non-covered indications will be denied. Reference the current policy at http://apps.humana.com/tad/tad_new/home.aspx before processing claims.