Medicare AdvantagePrior AuthMedium impact
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (Revised)
Humana·Ophthalmology, Pharmacy·Pharmacy
Effective date
Aug 27, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Ophthalmic NSAID coverage policy for Medicare effective August 27, 2025. This is a step therapy policy requiring members to have failed or have contraindications/intolerances to Ilevro AND one additional NSAID (diclofenac, ketorolac, or flurbiprofen) before coverage approval for branded ophthalmic NSAIDs (Acular, Acular LS, Acuvail, BromSite, Nevanac, Prolensa, bromfenac). The policy maintains plan year approval duration for both initial and renewal requests.
Action Required
By August 27, 2025: Billing and prior authorization teams must implement step therapy verification for all Humana Medicare members requesting ophthalmic NSAIDs. Specifically: (1) Update authorization workflows to require documented evidence that the member has received previous treatment with Ilevro within the past 12 months OR has contraindication/intolerance to Ilevro; (2) Additionally verify that the member has received previous treatment with at least one of the following within the past 12 months OR has documented contraindication/intolerance: diclofenac ophthalmic solution, ketorolac ophthalmic solution, or flurbiprofen ophthalmic solution; (3) Train prior authorization staff and ophthalmology office staff on the dual-step requirement; (4) Update preauthorization request forms to collect documentation of prior NSAID therapy or intolerance; (5) Configure billing system to flag claims for Acular, Acular LS, Acuvail, BromSite, Nevanac, Prolensa, or bromfenac without dual-step verification. Claims submitted without evidence of both step therapy criteria will be denied. Contact Humana at the PAL (Preauthorization and Notification List) portal at www.humana.com/PAL for claim code specifics.