CommercialPrior AuthMedium impact
Megace® ES (megestrol acetate) (Revised)
Humana·Oncology, Palliative Care, Infectious Disease +1 more·Commercial
Effective date
Aug 28, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its Megace ES (megestrol acetate) pharmacy coverage policy effective August 28, 2024. The policy maintains step therapy requirements, now explicitly requiring members to have had previous treatment or intolerance to megestrol before approval. This is a policy clarification/revision rather than a substantive coverage change, but billing teams must ensure prior authorization workflows align with the updated step therapy criterion.
Action Required
By September 15, 2024: Billing and prior authorization teams must verify that Humana's step therapy requirement for Megace ES is correctly configured in the authorization system. Specifically: (1) Ensure prior authorization is required for all Megace ES (megestrol oral suspension) claims; (2) Verify that the authorization system flags claims where the member does NOT have documented previous treatment or intolerance to megestrol, as these will be denied; (3) Update provider communications and billing staff training to clarify that Megace ES requires documentation of prior megestrol therapy or documented intolerance before approval; (4) Confirm with Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL for current coding requirements. Failure to properly document prior treatment history will result in claim denials. Note: This policy applies to pharmacy-billed Megace ES only; verify applicability for medically billed requests through the PAL system.