Medicare AdvantagePrior AuthMedium impact
Reltone™ (ursodiol capsule) (Revised)
Humana·Gastroenterology, General Surgery, Internal Medicine +1 more·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Reltone (ursodiol capsule) prior authorization policy effective April 22, 2026. The policy requires prior authorization for Reltone use in two indications: gallstone treatment (for radiolucent, noncalcified stones <20mm) and gallstone prevention (during rapid weight loss), with the requirement that members must have had previous treatment or intolerance with generic ursodiol tablets or 300mg capsules. Coverage is limited to plan-year durations with an important safety limitation that use beyond 24 months is not established.
Action Required
By April 22, 2026: Billing team must update prior authorization workflows in billing system to flag all Reltone (ursodiol capsule) prescriptions for Humana Medicare Advantage members. Ensure system captures: (1) indication (gallstone treatment vs. prevention), (2) stone characteristics (radiolucent, noncalcified, <20mm for treatment indication), and (3) documentation of prior generic ursodiol treatment or documented intolerance. Providers must include treatment history in prior auth requests. Update encounter forms and billing templates with these requirements. Front desk staff should alert providers submitting Reltone claims that prior authorization is required before dispensing. Implement monthly compliance check to ensure all Reltone claims for Humana MA members include required documentation. Claims submitted without meeting criteria or lacking prior authorization will be denied. Flag any claims for use beyond 24 months for medical review.