Medicare AdvantagePrior AuthMedium impact
Emflaza® (deflazacort) (Revised)
Humana·Neurology, Pediatrics, Genetics·Medicare Advantage
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
Humana updated its Emflaza (deflazacort) prior authorization policy for Medicare Advantage, effective January 1, 2020, with a revision date of October 22, 2025. The policy requires prior authorization for deflazacort and its brand equivalents (Jaythari, Pyquvi, Kymbee) for Duchenne Muscular Dystrophy treatment in patients who meet specific criteria: confirmed DMD diagnosis via genetic testing, muscle weakness onset before age 5, and prior prednisone treatment for at least 6 months with documented undesirable weight gain (>20% increase requiring dose reduction) or severe behavioral adverse effects. This is a routine policy update with no substantive coverage criteria changes from the original 2020 policy.
Action Required
No immediate action required. This policy revision on October 22, 2025 contains no changes to prior authorization requirements or clinical criteria from the original January 1, 2020 effective date. However, billing and prior authorization staff should verify they are using the current online version (dated 10/22/2025) rather than any printed or cached copies. Providers submitting Emflaza prior authorization requests must ensure claims documentation includes: (1) genetic testing confirmation of DMD diagnosis, (2) documentation of muscle weakness onset before age 5, and (3) evidence of prior prednisone therapy for at least 6 months with either documented weight gain exceeding 20% of baseline requiring dose adjustment OR documented severe behavioral adverse effects (irritability, aggression) requiring dose reduction. Claims lacking this documentation will be denied.