Medicare AdvantagePrior AuthLow impact
Scenesse® (afamelanotide) (Revised)
Humana·FL · Dermatology, Genetics, Internal Medicine +1 more·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Scenesse® (afamelanotide) prior authorization policy for Medicare and Medicaid-Florida on November 26, 2025. The policy maintains coverage for this rare drug treatment for erythropoietic protoporphyria (EPP) in adult patients who meet specific diagnostic and clinical criteria. Billing teams must ensure prior authorization is obtained before dispensing this subcutaneous implant, and providers must document confirmed EPP diagnosis plus history of phototoxic cutaneous reactions.
Action Required
By December 26, 2025: Billing and pharmacy teams must verify this revised policy is loaded in their prior authorization system. Before processing any Scenesse® (afamelanotide) claims: (1) Confirm member has documented diagnosis of EPP confirmed by elevated free erythrocyte protoporphyrin OR pathogenic FECH gene variants on molecular testing; (2) Confirm member has documented history of phototoxic cutaneous reactions (pain, stinging, redness, swelling); (3) Obtain prior authorization before claim submission for Medicare and Medicaid-Florida members. Update internal documentation to note the November 26, 2025 revision date. Contact Humana directly via www.humana.com/PAL for specific medical and procedural coding guidance. Claims submitted without prior authorization or incomplete documentation will be denied.