Medicare AdvantagePrior AuthMedium impact
Bimzelx (bimekizumab-bkzx) (Revised)
Humana·Dermatology, Rheumatology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 1, 2026
Summary
This is a revised Medicare Advantage prior authorization policy for Bimzelx (bimekizumab-bkzx), effective January 1, 2026, with a June 24, 2026 revision. The policy establishes specific prior authorization criteria for five approved indications: plaque psoriasis, psoriatic arthritis, non-radiographic axial spondyloarthritis, ankylosing spondylitis, and hidradenitis suppurativa. All requests require prior auth, with varying pre-treatment requirements (typically 2 prior failed therapies) depending on the diagnosis.
Action Required
By January 1, 2026, the billing and clinical authorization team must: (1) Update the prior authorization system to flag all Bimzelx (bimekizumab-bkzx) requests as requiring prior auth before claims submission; (2) Configure the system to verify member meets diagnosis-specific criteria: plaque psoriasis and hidradenitis suppurativa require moderate-to-severe diagnosis and 2 failed prior therapies; psoriatic arthritis, non-radiographic axial spondyloarthritis, and ankylosing spondylitis require active disease and 2 failed prior therapies; (3) All approvals require member age ≥18 years; (4) Update prior auth request forms to capture prior therapy history for adalimumab, Enbrel, Cosentyx, Skyrizi, ustekinumab, Tremfya, and Rinvoq (as applicable by diagnosis); (5) Communicate to prescribing providers (especially dermatologists and rheumatologists) that Bimzelx requires prior auth and specific pre-treatment documentation; (6) Reference www.humana.com/PAL for medical claim coding. Note: Approval duration not specified in policy; verify with Humana. Claims submitted without required prior authorization will be denied.