Medicare AdvantagePrior AuthMedium impact
Nuplazid® (pimavanserin) (Revised)
Humana·Neurology, Psychiatry, Geriatrics·Medicare Advantage
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
Humana updated its Nuplazid® (pimavanserin) prior authorization policy for Medicare Advantage members on February 25, 2026. The policy requires prior authorization for this drug when used to treat hallucinations and delusions associated with Parkinson's disease psychosis. Three specific criteria must be met: member must be using Nuplazid for PD psychosis symptoms, psychosis must have appeared after PD diagnosis, and psychosis must not be related to other causes. The policy includes a black box warning clarifying that Nuplazid is not approved for dementia-related psychosis unless hallucinations are directly related to Parkinson's disease.
Action Required
By March 15, 2026: Billing team must implement prior authorization requirements for Nuplazid (pimavanserin) claims for Medicare Advantage members. Update billing software to flag all Nuplazid prescriptions for prior auth verification before claim submission. Providers should document in patient records: (1) confirmation of Parkinson's disease diagnosis, (2) timing of psychosis onset relative to PD diagnosis, and (3) confirmation that psychosis is not attributable to other causes. Add these three criteria to prior auth request forms and EMR templates. Front desk staff should alert providers when ordering Nuplazid that prior authorization is required. Claims submitted without documented evidence of meeting all three criteria will be denied by Humana. Reference the policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a4cad15 for current requirements.