Medicare AdvantagePrior AuthMedium impact
Duloxetine Containing Products (Revised)
Humana·Psychiatry, Internal Medicine, Family Medicine +3 more·Medicare Advantage
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for Duloxetine-containing products (Drizalma Sprinkle) effective September 24, 2025. The policy requires prior authorization for duloxetine use in Medicare Advantage members with MDD, GAD, or DPNP (only after failure/intolerance with venlafaxine AND lower-dose duloxetine), and for chronic musculoskeletal pain or fibromyalgia (after failure/intolerance with duloxetine). Approval is granted for the plan year duration for both initial and renewal requests.
Action Required
By September 24, 2025: Billing and clinical teams must implement prior authorization requirements for Drizalma Sprinkle (duloxetine delayed-release capsules in 20mg, 30mg, 40mg, and 60mg) for all Medicare Advantage members. (1) Update billing system to flag prescriptions for Drizalma Sprinkle requiring prior authorization before claim submission. (2) Providers must document member's diagnosis (MDD, GAD, DPNP, chronic musculoskeletal pain, or fibromyalgia) and prior therapy/intolerance history with venlafaxine and/or duloxetine lower doses on authorization requests. (3) Front desk and clinical staff should communicate to members that prescriptions may require prior authorization approval before dispensing. (4) Route all Drizalma Sprinkle requests through Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL for medically billed claims. Failure to obtain prior authorization will result in claim denials and potential member out-of-pocket costs.