Medicare AdvantagePrior AuthLow impact
Krystexxa® (pegloticase) (Revised)
Humana·KY, SC · Rheumatology, Internal Medicine·Medicaid
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Krystexxa (pegloticase) prior authorization policy effective January 28, 2026, for Medicare, Medicaid-Kentucky, and Medicaid-South Carolina members. This is a routine policy update with no changes to coverage criteria, approval duration, or clinical requirements. The policy maintains six mandatory criteria for approval including chronic gout diagnosis, baseline uric acid >6 mg/dL, methotrexate co-therapy, G6PD deficiency screening, treatment refractoriness, and prior allopurinol exposure/contraindication.
Action Required
No immediate action required. This is a routine revision with no substantive changes to prior authorization requirements or clinical criteria. Billing and clinical teams should verify this is the current active policy version on Humana's system before processing Krystexxa authorization requests. Confirm internal workflows align with the six approval criteria listed in the policy.