MedicaidPrior AuthMedium impact
Durysta® (bimatoprost implant) (Revised)
Humana·FL, KY, SC · Ophthalmology·Medicaid
Effective date
Jun 1, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Durysta (bimatoprost implant) prior authorization policy effective June 1, 2026, for Florida, Kentucky, and South Carolina Medicaid. The policy maintains strict approval criteria requiring open angle glaucoma/ocular hypertension diagnosis and no prior Durysta treatment on the affected eye, with three key clinical exclusions (corneal endothelial dystrophy, prior corneal transplant, absent/ruptured posterior lens capsule). Billing teams must ensure prior authorization is obtained before claims submission for these state Medicaid programs.
Action Required
By June 1, 2026: Billing team must implement prior authorization requirement for all Durysta (bimatoprost implant) claims submitted to Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. Before submitting any Durysta claims, verify member meets BOTH approval criteria: (1) diagnosis of open angle glaucoma or ocular hypertension documented, and (2) treated eye has NOT received prior Durysta treatment. Confirm member does NOT have ANY of the three exclusions (corneal endothelial cell dystrophy, prior corneal transplantation, or absent/ruptured posterior lens capsule). Update billing system workflow to require prior authorization documentation before claim submission. Alert ophthalmology providers to obtain written prior authorization from Humana before administering Durysta in these states. Claims submitted without prior authorization will be denied. Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for claim code submission instructions.