Medicare AdvantagePrior AuthMedium impact
Orladeyo (berotralstat) (Revised)
Humana·SC · Internal Medicine, Allergy & Immunology·Medicaid
We identified it
Jul 21, 2026
Summary
This is a revised Prior Authorization policy for Orladeyo (berotralstat), a medication for hereditary angioedema. The policy applies to Medicare and Medicaid members in South Carolina and establishes new or updated requirements for obtaining prior authorization before dispensing this drug. Billing teams must verify authorization requirements and implement changes to claims processing workflows.
Action Required
Immediately: Obtain the full policy document from the provided URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a58482a) to extract specific prior authorization criteria, required documentation, and approval timelines. Billing team must: (1) Update prior authorization submission procedures in billing software for Orladeyo claims; (2) Train pharmacy/clinical staff on new authorization requirements before submitting claims; (3) Establish process to verify prior auth approval before dispensing medication to South Carolina Medicare and Medicaid members; (4) Flag all Orladeyo claims for manual review until authorization procedures are confirmed. NOTE: This analysis is based on summary-only information. The source document must be reviewed to identify specific affected HCPCS codes (likely J-codes for the drug), effective date, and detailed authorization requirements. Claims submitted without proper authorization may be denied.