Medicare AdvantagePrior AuthMedium impact
Serostim® (somatropin) (Revised)
Humana·Infectious Disease, Internal Medicine·Medicare Advantage
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Serostim (somatropin) prior authorization policy effective January 28, 2026. The policy maintains existing coverage criteria for HIV-associated wasting/cachexia treatment but clarifies diagnostic thresholds, requires concomitant antiretroviral therapy, and mandates prior treatment/contraindication/intolerance with Marinol or Megace. All requests require prior authorization, with approvals granted for plan year durations.
Action Required
By January 28, 2026: Billing team must ensure all Serostim (somatropin) claims for Medicare Advantage members include prior authorization before submission. Update billing system to require prior auth documentation for HCPCS code J2941. Verify medical records contain evidence of: (1) HIV wasting/cachexia diagnosis meeting specific weight loss or body composition criteria, (2) concurrent antiretroviral therapy, and (3) previous trial/contraindication/intolerance to Marinol or Megace. Providers must document all three criteria in claims; absence of any criterion will result in claim denial. Train front desk and billing staff on revised diagnostic thresholds. Update prior authorization submission templates to reflect all three mandatory criteria.