Medicare AdvantagePrior AuthMedium impact
Crofelemer Products (Revised)
Humana·Infectious Disease, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Crofelemer (Mytesi) prior authorization policy effective January 28, 2026. The policy maintains prior authorization requirements for non-infectious diarrhea treatment in HIV/AIDS patients on antiretroviral therapy, with four mandatory approval criteria: HIV/AIDS diagnosis, current antiretroviral therapy, non-infectious diarrhea diagnosis, and documented failure/intolerance to loperamide or diphenoxylate/atropine. Billing teams must ensure all Mytesi claims include prior authorization and meet all four criteria before submission.
Action Required
By January 28, 2026: Billing team must update authorization tracking system to enforce the four approval criteria for all Mytesi (crofelemer) claims under Humana Medicare Advantage plans. Specifically: (1) Verify member has documented HIV/AIDS diagnosis before submitting claims; (2) Confirm current antiretroviral therapy in medical record; (3) Document non-infectious diarrhea diagnosis; (4) Obtain evidence of prior failure, intolerance, or contraindication to loperamide or diphenoxylate/atropine. Update prior authorization request templates to include all four criteria checkboxes. Train providers to document medication history in encounter notes. All Mytesi claims submitted without complete prior authorization will be denied. Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for current medical/procedural coding requirements.