Medicare AdvantagePrior AuthMedium impact
Zurzuvae® (zuranolone) (Revised)
Humana·Psychiatry, OB-GYN, Family Medicine +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Sep 2, 2026
Summary
Humana Medicare Advantage has established a revised prior authorization policy for Zurzuvae® (zuranolone) for postpartum depression treatment, effective January 1, 2026. The policy requires prior authorization and defines strict eligibility criteria including diagnosis timing, treatment window (within 1 year postpartum), and a single 14-day course limitation per episode. Billing teams must implement prior authorization workflows and ensure claims compliance with these new requirements.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements for all Zurzuvae® claims submitted to Humana Medicare Advantage plans. (1) Update billing system to flag Zurzuvae® prescriptions for mandatory prior authorization before claim submission. (2) Providers must document in patient records: patient age (≥18), DSM-5 major depressive episode diagnosis with validated depression rating scale score (HAM-D, MADRS, or PHQ-9), symptom onset timing (third trimester or within 4 weeks of delivery), postpartum timeline (within 1 year), non-pregnant status at initiation, and confirmation this is the single 14-day course for the current episode. (3) Billing team submits prior authorization requests through Humana with required clinical documentation; initial approval valid 30 days, renewals valid 30 days. (4) Before dispensing, obtain and verify prior authorization approval number. (5) Advise providers of black box warning regarding CNS impairment and driving restrictions—patients must wait ≥12 hours post-administration before driving. Failure to obtain prior authorization will result in claim denials. Contact Humana PAL at www.humana.com/PAL for procedural coding guidance and preauthorization submission.