Medicare AdvantagePrior AuthLow impact
Procysbi® (cysteamine) (Revised)
Humana·Pediatrics, Nephrology, Internal Medicine·Medicare Advantage
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Procysbi® (cysteamine) prior authorization policy effective March 25, 2026. The policy requires prior authorization for this rare disease medication and mandates that members have a confirmed diagnosis of nephropathic cystinosis AND prior treatment or documented intolerance to Cystagon (cysteamine) before coverage approval. This is a routine revision to an existing policy with no substantive coverage changes from the original effective date.
Action Required
By March 25, 2026: Billing and prior authorization teams should verify that the practice's authorization software reflects the two-criterion requirement for Procysbi approvals: (1) nephropathic cystinosis diagnosis and (2) prior Cystagon treatment or documented intolerance. When submitting prior auth requests for Procysbi, ensure clinical documentation clearly establishes both criteria are met. This affects a very small patient population with rare disease. No claim submission workflow changes are anticipated as this is a standard prior auth policy update. Consult www.humana.com/PAL for applicable HCPCS codes if medically billing requests.