CommercialPrior AuthMedium impact
Ezetimibe-Containing Products (Revised)
Humana·Cardiology, Internal Medicine, Family Medicine +2 more·Commercial
Effective date
May 22, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its Ezetimibe-Containing Products step therapy policy effective May 22, 2024. The policy requires members to have prior treatment with two generic statins (atorvastatin, lovastatin, pravastatin, simvastatin, or rosuvastatin) before coverage of Zetia or Vytorin products. This is a reconfirmation/clarification of existing step therapy requirements for commercial plans, with approval granted for the initial plan year duration.
Action Required
By May 22, 2024 (retroactive as of revision date): Billing and authorization teams must ensure prior authorization processes for Zetia (ezetimibe) and Vytorin (10-10, 10-20, 10-40, 10-80 tablets) enforce the step therapy requirement. Before processing claims or authorizations, verify member has documented treatment history with at least TWO of the following generic statins: atorvastatin, lovastatin, pravastatin, simvastatin, or rosuvastatin. Update authorization request templates and billing software validation rules to capture statin history. Deny or request additional documentation for claims lacking evidence of prior statin trials. Notify providers that members must exhaust step therapy criteria before Zetia/Vytorin will be covered. Verify member health plan benefits as of service date and confirm this is current policy via Humana's TAD portal before authorizing any claims.