Medicare AdvantagePrior AuthMedium impact
Viltepso™ (viltolarsen) (Revised)
Humana·KY, SC · Neurology, Pediatrics·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Viltepso (viltolarsen) prior authorization policy effective December 17, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains existing coverage criteria for this exon 53 skipping therapy in Duchenne Muscular Dystrophy patients, requiring confirmation of DMD gene mutation, specialist prescription, baseline corticosteroid stability, ambulatory status, baseline functional assessments, and prohibition of concurrent exon 53 skipping therapies. Prior authorization remains required for all initial and renewal requests.
Action Required
By December 17, 2025: Billing team must ensure prior authorization processes are in place for Viltepso claims from Kentucky and South Carolina Medicaid and Medicare patients. Update prior authorization submission templates to require: (1) confirmation of DMD gene mutation amenable to exon 53 skipping, (2) documentation of specialist prescription (neurologist), (3) proof of baseline corticosteroid stability or documented contraindication/intolerance, (4) verification of ambulatory status at initiation, (5) baseline functional assessment results (6MWT, 10MWT, or NSAA), and (6) confirmation that no other exon 53 skipping therapies (e.g., Vyondys 53) are being used concurrently. For renewal requests, require documentation of improvement or maintenance of functional status compared to predicted natural disease progression. Claims submitted without complete prior authorization documentation will be denied. Front desk and clinical staff should flag Viltepso prescriptions for immediate prior auth routing.