CommercialPrior AuthMedium impact
Niacin-containing agents (Revised)
Humana·Cardiology, Internal Medicine, Pharmacy·Commercial
Effective date
Jan 24, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its niacin extended-release prior authorization policy effective January 24, 2024. The policy requires prior authorization for niacin ER tablets for commercial members with either severe hypertriglyceridemia (TG >500 mg/dL) or hyperlipidemia/mixed dyslipidemia, with mandatory evidence of prior treatment failure or contraindication to specific generic fibrates and statins before approval.
Action Required
By January 24, 2024: Billing and clinical staff must implement prior authorization requirements for all niacin ER prescriptions (500mg, 750mg, 1000mg tablets) on Humana commercial plans. Before submitting claims: (1) Verify member has documented failure of or contraindication to generic fenofibrate AND generic gemfibrozil for severe hypertriglyceridemia cases (TG >500 mg/dL), OR failure of generic statin AND one fibrate/gemfibrozil for hyperlipidemia cases; (2) Obtain prior authorization through Humana's system before dispensing; (3) Document triglyceride levels and prior medication trials in the authorization request. Update pharmacy billing software and clinical decision support to flag niacin ER prescriptions for mandatory prior auth review. Educate prescribers that claims will be denied if prior authorization is not obtained or medical necessity criteria are not met. Verify current policy at http://apps.humana.com/tad/tad_new/home.aspx before processing each claim.