Medicare AdvantagePrior AuthMedium impact
Antipsychotic Utilization Program (Revised)
Humana·FL, SC, IN, OK, VA · Psychiatry, Geriatrics, Pharmacy·Medicaid
Effective date
Jun 10, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Antipsychotic Utilization Program (effective June 10, 2026) to strengthen prior authorization requirements for atypical and typical antipsychotic medications in members with dementia. The policy now requires prior auth when members 65+ with dementia receive a new antipsychotic prescription without compendia-supported diagnoses (schizophrenia, bipolar disorder, Huntington's disease, Tourette's syndrome) or documented dangerous/severe dementia-related psychosis. This aligns with Beers Criteria guidance and CMS compliance efforts to reduce inappropriate antipsychotic use in elderly patients.
Action Required
By June 10, 2026: Billing and prior authorization teams must update systems to flag ALL new antipsychotic prescriptions (Table A medications: aripiprazole, risperidone, quetiapine, olanzapine, paliperidone, clozapine, ziprasidone, brexpiprazole, cariprazine, iloperidone, lurasidone, asenapine, lumateperone, pimavanserin, and first-generation agents) for members 65+ with identified dementia diagnoses (ICD-10 codes F01.50-F01.51, F02.80-F02.81, F03.90-F03.91, G30.0-G30.9, G31.01, G31.83, or dementia medication claims per Table B). Providers must document one of the following to obtain approval: (1) compendia-supported indication (schizophrenia 295.0x-295.9x, bipolar disorder 296.0x/296.1x/296.4x-296.9x, Huntington's disease 333.4, or Tourette's syndrome 307.23), OR (2) dangerous/severe dementia-related psychosis with safety risks. Prior authorization staff must deny requests for dementia-only psychosis in members 65+ without an approvable compendia diagnosis per Exclusion #1. Update encounter forms and pharmacy workflows in all affected state plans (FL, SC, IN, OK, VA) and Medicare Advantage/Traditional Medicare lines. Failure to obtain prior auth will result in claim denials and potential compliance violations with CMS/MIG oversight.