Medicare AdvantagePrior AuthMedium impact
Xermelo™ (telotristat ethyl) (Revised)
Humana·Oncology, Gastroenterology, Internal Medicine·Medicare Advantage
Effective date
Apr 5, 2017
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated the Xermelo (telotristat ethyl) prior authorization policy on October 22, 2025. The policy maintains existing coverage criteria for carcinoid syndrome diarrhea treatment but reinforces that prior authorization is required for initial approval (6 months) and renewal (6 months), with specific clinical criteria that must be met including 3 months of prior SSA therapy at stable dose and concomitant SSA use. The revision date indicates this is a current, active policy requiring immediate compliance.
Action Required
Immediately: Billing team must verify all Xermelo (telotristat ethyl) claims for Medicare Advantage members include prior authorization before submission. Implement the following prior auth requirements in billing system: (1) Verify member age ≥18 years; (2) Confirm diagnosis of carcinoid syndrome diarrhea inadequately controlled on SSA therapy; (3) Document 3 months of prior SSA therapy (octreotide acetate, Sandostatin LAR, or Somatuline Depot) at stable dose; (4) Confirm concomitant SSA use with Xermelo. For renewal requests after initial 6-month approval, verify member has not experienced severe constipation/abdominal pain and Xermelo demonstrates clinical benefit (maintained reduction in daily bowel movements from baseline). Update prior authorization templates and provider communication materials to reflect these criteria. Communicate revised policy to all providers prescribing Xermelo. Claims submitted without documented prior authorization will be denied. Route all Xermelo requests through Humana's PAL system (www.humana.com/PAL) for prior authorization processing.