Medicare AdvantagePrior AuthMedium impact
Inqovi® (decitabine and cedazuridine) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Aug 12, 2026
Summary
Humana Medicare Advantage revised its prior authorization policy for Inqovi® (decitabine and cedazuridine) effective January 1, 2026, with a revision dated June 24, 2026. The policy establishes coverage criteria for two indications: myelodysplastic syndromes (MDS)/CMML as a single agent, and newly diagnosed acute myeloid leukemia (AML) in patients 75+ or with comorbidities precluding intensive chemotherapy when used with venetoclax. Billing teams must implement prior authorization requirements and verify member eligibility against these specific clinical criteria before claims submission.
Action Required
By December 15, 2025: Billing team and prior authorization staff must implement the following changes: (1) Configure billing system to require prior authorization for all Inqovi claims on Medicare Advantage plans; (2) Create prior auth checklist requiring documentation of: diagnosis (MDS, CMML, or newly diagnosed AML), patient age (75+ for AML), comorbidities if applicable, confirmation of single-agent use for MDS or combination with venetoclax for AML, and proof that patient has NOT progressed on prior hypomethylators (azacitidine or decitabine); (3) Update claim submission workflow to block Inqovi claims without approved prior auth; (4) Notify ordering providers of new/updated authorization requirements via staff communication; (5) Establish process to verify comorbidity documentation for AML cases. Claims submitted without prior authorization will be denied. All staff processing Inqovi requests must review the full 3-page policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5a132e before authorization approval.