← Back to list
Janumet (sitagliptin and metformin hydrochloride) (New)
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Oct 2, 2026
Summary
Humana Medicare Advantage has implemented a new prior authorization requirement for Janumet (sitagliptin/metformin) effective January 1, 2027. Coverage requires patients to have type 2 diabetes and either tried or be unable to use generic sitagliptin/metformin, with a critical exclusion: patients with a history of pancreatitis are not eligible. This is a brand-to-generic step therapy policy.
Get alerts when payers change rules like this one
We check Humana and other payers every day and email you when a change matches your specialty and state.
Get Humana alertsPolicy Monitoring is free. No card required.
What to do
by Dec 31, 2026 · 7 steps
01Billing team must implement prior authorization workflow for all Janumet (sitagliptin/metformin) prescriptions for Medicare Advantage members.
02Update billing software and pharmacy systems to require prior auth submission before dispensing.
03Create or modify encounter forms/templates to capture: patient diagnosis of type 2 diabetes, documented trial or documented reason patient cannot use generic sitagliptin/metformin, and confirmation that patient has NO history of pancreatitis.
04Brief clinical staff that claims for patients with pancreatitis history will be denied regardless of other criteria.
05Configure system to automatically flag Janumet requests for MA members requiring PA documentation.
06Failure to obtain prior authorization will result in claim denials and potential member out-of-pocket costs.
07Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for specific medical and procedural coding requirements.
Original notice
Janumet (sitagliptin and metformin hydrochloride) (New)
mcp.humana.com · Always check the source before changing claims.