Medicare AdvantagePrior AuthMedium impact
Leqvio® (inclisiran) (Revised)
Humana·SC · Cardiology, Internal Medicine, Family Medicine +2 more·Medicaid
Effective date
Jan 1, 2026
We identified it
Sep 11, 2026
Summary
Humana has revised its Leqvio (inclisiran) prior authorization policy effective January 1, 2026, with an update dated August 26, 2026. The policy now covers this PCSK9 inhibitor for hypercholesterolemia and familial hypercholesterolemia in specific patient populations (age 18+ for general hypercholesterolemia; age 12+ for HeFH and pediatric HoFH), requiring documented statin failure or statin-associated muscle symptoms, and step therapy with Repatha for MAPD and SC Medicaid plans. Billing teams must implement prior authorization requirements and verify step therapy compliance before claim submission.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements in billing system for Leqvio (inclisiran) HCPCS code J3301. For MAPD and SC Medicaid members, require documentation of previous Repatha (evolocumab) treatment, contraindication, or intolerance before submitting claims. Update claim submission workflows to include: (1) verification of member age (18+ for hypercholesterolemia; 12+ for HeFH/HoFH), (2) confirmation of maximally tolerated statin therapy trial or documented statin-associated muscle symptoms (SAMs), (3) step therapy verification with Repatha for MAPD/SC Medicaid plans, and (4) LDL-C goal achievement data. Create authorization form templates for providers specifying these criteria. Train billing and prior auth staff on age-based eligibility and statin failure documentation requirements. Failure to obtain prior authorization will result in claim denials. Refer providers to www.humana.com/PAL for medical billing codes and preauthorization requirements.