Medicare AdvantagePrior AuthMedium impact
Orilissa® (elagolix) (Revised)
Humana·OB-GYN·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Orilissa (elagolix) prior authorization policy effective April 22, 2026. The policy maintains existing coverage criteria for endometriosis pain management but clarifies treatment duration limits: maximum 6 months at 200mg dosing or 24 months at 150mg dosing. All prior authorization requirements and clinical criteria remain unchanged from the original October 2018 policy.
Action Required
By April 22, 2026: Billing and prior authorization team must update internal guidelines to reflect the revised duration limits for Orilissa therapy. When processing prior authorization requests and renewal claims for Humana Medicare Advantage members, verify that: (1) Initial authorization does not exceed 6 months for 200mg dosing or 24 months for 150mg dosing, (2) Renewal requests confirm cumulative therapy duration stays within these limits, and (3) Claims are flagged and denied if therapy exceeds maximum permitted duration. Update PA request templates and billing software decision rules to enforce these thresholds. Educate providers that therapy extending beyond 6 months (200mg) or 24 months (150mg) will not be covered. Communicate revised policy to all OB-GYN and women's health providers in your network.