CommercialPrior AuthMedium impact
Nitisinone Products (Revised)
Humana·Pediatrics, Internal Medicine, Genetics +1 more·Commercial
Effective date
Feb 28, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its prior authorization policy for nitisinone products (Orfadin capsule/suspension and generic nitisinone capsules) effective February 28, 2024. The policy now requires prior authorization for all nitisinone products used to treat hereditary tyrosinemia type 1 (HT-1), with three approval criteria: confirmed HT-1 diagnosis, plasma tyrosine level below 500 micromol/L on a restricted diet, and previous treatment or documented intolerance to generic nitisinone capsules. Approvals are granted for plan year durations or as determined through clinical review.
Action Required
By March 30, 2024: Billing team must implement prior authorization requirements for all nitisinone prescriptions (Orfadin capsule, Orfadin oral suspension, and generic nitisinone capsule) submitted to Humana commercial plans. Update billing system to flag nitisinone claims for mandatory prior auth submission. Providers must document: (1) HT-1 diagnosis confirmation, (2) current plasma tyrosine level below 500 micromol/L on tyrosine/phenylalanine-restricted diet, and (3) evidence of previous generic nitisinone treatment or documented intolerance. Front desk and clinical staff should add a prior auth checklist to encounter workflows for any HT-1 patient requesting nitisinone. Claims submitted without prior authorization will be denied. Direct providers to submit requests via www.humana.com/PAL for medical billing inquiries. Verify this is the current version at http://apps.humana.com/tad/tad_new/home.aspx before processing any claims.