PAYER POLICY CHANGES

Kentucky Medicaid Policy Changes

Policy changes from Kentucky Medicaid and from Medicaid managed care plans in Kentucky, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.

UnitedHealthcare · Effective Jan 1, 2027Medium impact
Saphnelo® (Anifrolumab-Fnia)
UnitedHealthcare Community Plan of Kentucky revised its Saphnelo (anifrolumab-fnia) medical benefit drug policy for moderate to severe SLE, adding a criterion that the prescriber attest the patient or caregiver cannot be trained or is physically unable to self-administer Saphnelo or Benlysta (FDA-labeled for self-administration) and submit an explanation, for both initial and continuation requests. Practices should update prior authorization submissions for these infusions to include the attestation and explanation, and confirm the patient meets the Benlysta failure/contraindication/intolerance history before requesting authorization.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Pasatru™ (Garetosmab-Grts)
UnitedHealthcare Community Plan of Kentucky added a medical benefit drug policy for Pasatru (garetosmab-grts) under its Medicaid plan in Kentucky, effective 2026-12-01. Initial therapy requires the patient to be over 18, a fibrodysplasia ossificans progressiva (FOP) diagnosis, supporting chart notes and genetic confirmation of an ACVR1 mutation, prescribing by or with an FOP expert, dosing per FDA labeling, and no combined use with Sohonos (palovarotene), with authorizations up to 12 months; continuation requires documented positive response and the same conditions.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Omalizumab
UnitedHealthcare's Kentucky Medicaid medical policy for omalizumab was revised to refer to all omalizumab products generically, listing Omlyclo (omalizumab-igec), Xolair, and any FDA-approved and launched biosimilar not named (which is treated as non-preferred until reviewed). HCPCS code Q5154 was added, and the policy clarifies that self-administered subcutaneous omalizumab is obtained under the pharmacy benefit rather than the medical benefit. The revised policy is effective 2026-12-01.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease
UnitedHealthcare Community Plan of Kentucky revised its Medicaid medical benefit policy for Alzheimer's disease amyloid-directed monoclonal antibodies (Kisunla and Leqembi). Continuation-of-therapy criteria now require an Alzheimer's diagnosis and ARIA MRI monitoring per FDA labeling, drop the requirement for submitted follow-up MRI chart notes, and add new criteria for the intravenous Leqembi 10 mg/kg dosing regimens. Leqembi IQLIK subcutaneous self-injection is routed to the pharmacy benefit.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Maximum Dosage and Frequency
UnitedHealthcare Community Plan of Kentucky revised its Maximum Dosage and Frequency medical benefit drug policy, updating the list of maximum allowed quantities and frequencies by HCPCS units and adding Exdensur (depemokimab) and Spinraza (nusinersen). Billing teams should check claims for these drugs against the listed per-administration maximums and dosing frequencies, and confirm that HCPCS codes J2326 and J2361 are added to charge entry and that the revised descriptions for Q5136 and Q5157 are reflected in the charge master.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Ilaris ® (Canakinumab)
UnitedHealthcare Community Plan of Kentucky updated its Ilaris (canakinumab) medical benefit drug policy for Medicaid members in Kentucky, effective 2026-12-01. For Active Still's Disease, including Adult-Onset Still's Disease (AOSD) and Systemic Juvenile Idiopathic Arthritis (SJIA), the coverage rationale now states that the patient must not be receiving Ilaris in combination with another systemic targeted immunomodulator for the same indication.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Hereditary Angioedema (HAE), Treatment and Prophylaxis
UnitedHealthcare Community Plan of Kentucky updated its Medicaid medical benefit drug policy for hereditary angioedema (HAE) treatment and prophylaxis, with the update status and an effective date of 2026-11-01 stated in the bulletin. The list of applicable CPT codes was refreshed to reflect quarterly edits, and codes 0678U and 0679U were added. Billing teams should update their charge entry and claim edits for these Kentucky Medicaid members so claims carry the newly listed codes.
UnitedHealthcare · Effective Dec 1, 2026Low impact
Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)
UnitedHealthcare Community Plan of Kentucky published a Medicaid medical benefit drug policy for Genglycos (pariglasgene brecaparvovec-opnr), a gene therapy for glycogen storage disease type Ia, effective 2026-12-01. Coverage is limited to patients 8 years or older who meet diagnostic confirmation, cornstarch therapy, AAV8 antibody-negative, no prior gene therapy, metabolic specialist involvement, no planned inpatient admission solely for administration, FDA-labeled dosing, and an authorization limit of one lifetime treatment valid for no more than 45 days from approval.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
FcRn Blockers
UnitedHealthcare Community Plan of Kentucky revised its FcRn Blockers medical benefit drug policy, effective 2027-01-01, to state that Imaavy is proven and medically necessary for warm autoimmune hemolytic anemia (wAIHA) in adults and children 12 and older currently or previously treated with corticosteroids, subject to specified diagnostic, treatment-history, dosing and prescriber criteria. ICD-10 code D59.11 was added to the applicable codes, and the policy covers Imaavy, Rystiggo, Vyvgart and Vyvgart Hytrulo vial for administration by a healthcare professional.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
UnitedHealthcare Community Plan of Kentucky's Medicaid medical policy for denosumab was revised effective 2027-01-01, updating the list of covered denosumab products by adding Boncresa, Jubereq, Osvyrti, Oziltus, and Ponlimsi, with Jubereq and Osvyrti designated preferred and Boncresa, Oziltus, and Ponlimsi designated non-preferred. Coverage for postmenopausal osteoporosis treatment was revised to add an initial-therapy criterion for very high fracture risk (a fracture in the past 12 months or a fracture while on approved osteoporosis therapy), and HCPCS codes Q5166, Q5171, and Q5173 were added. Billing staff should update product and code references and review the new very-high-risk documentation requirements before submitting denosumab claims for these members.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) medical policy for Kentucky Medicaid members, with the revised policy effective 2027-01-01. Key changes include revised medical necessity criteria (the test must now be ordered by or in consultation with a medical geneticist, neonatologist, neurologist, immunologist, or developmental pediatrician), pretest genetic counseling now recommended rather than strongly recommended, state-specific reference to Kentucky Revised Statutes § 304.17A-263 for biomarker testing criteria, and eleven new CPT codes (0657U, 0658U, 0659U, 0670U–0677U) added to the applicable codes list.
UnitedHealthcare · Effective Nov 1, 2026Low impact
Video Electroencephalographic (vEEG) Monitoring and Recording (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky retired its medical policy for video electroencephalographic (vEEG) monitoring and recording, effective 2026-11-01. Under the retired policy, vEEG monitoring no longer requires clinical review for Kentucky Medicaid members.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Vascular Embolization: Select Procedures (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky's new Medicaid medical policy for vascular embolization, effective 2026-12-01, sets coverage limits: renal embolization is covered for preoperative or palliative treatment of renal cell carcinoma and for nonruptured angiomyolipomas at elevated bleeding risk, while arterial embolization for hemorrhoids and musculoskeletal pain (knee, shoulder osteoarthritis, adhesive capsulitis, tendinitis, plantar fasciitis) is deemed unproven and not medically necessary. The policy excludes members under 18 and acute/active bleeding indications, and points to InterQual and NCCN criteria for liver and other oncologic embolization.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Treatment of Temporomandibular Joint Disorders (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky revised its Medicaid medical policy on treatment of temporomandibular joint disorders, effective 2026-12-01. For members 18 and older and under 18, TMJ arthroplasty is now the only surgical service described as proven and medically necessary in certain circumstances, with InterQual criteria cited for each age group. Jaw mobility stretching devices were added to the unproven list, and CPT codes 21060, 21247, 29800, and 29804 were removed from the applicable codes.
UnitedHealthcare · Effective Nov 1, 2026Medium impact
Surgery of the Elbow (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky retired its Surgery of the Elbow medical policy, effective 2026-11-01, so elbow surgery for Kentucky Medicaid members no longer requires clinical review under that policy. Billing teams should stop routing these requests for clinical review and confirm that claims for elbow surgery for these members are set up without a clinical review step.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Kentucky Only)
Effective 2026-12-01, UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its stereotactic radiation therapy (SRS and SBRT) policy so that the listed proven-and-medically-necessary indications apply only when medical necessity cannot be determined using the referenced InterQual criteria. The indication list was also revised, adding intracranial arteriovenous malformations, and the policy applies to individuals 19 years of age or older, with SRS and SBRT covered without further review for those younger than 19.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)
Effective 2027-01-01, UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its molecular oncology testing policy for hematologic cancers. Kentucky members' medical necessity is now referred first to Kentucky Revised Statutes § 304.17A-263 biomarker testing criteria, and the policy adds clonoSEQ clonality/MRD coverage, lists specific proven multigene panel and comprehensive genomic profiling uses, and names EpiSwitch Checkpoint Inhibitor Response Test, optical genome mapping and whole-transcriptome sequencing as unproven.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Bariatric Surgery (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky removed CPT code 43882 from its Bariatric Surgery medical policy for Kentucky Medicaid members, as published in the November 2026 medical policy update bulletin. Billing staff should stop using 43882 on claims for these members and confirm the code is removed from charge entry and claim edit lists.
Kentucky Medicaid · Effective Oct 1, 2026Medium impact
Update to Inpatient Hospital Reimbursement - Effective October 1, 2026
Kentucky Medicaid (DMS) will limit inpatient hospital reimbursement for Hospital (01), Psychiatric DPU (92) and Rehabilitative DPU (93) provider types to the lesser of billed charges or the total allowed amount, effective October 1, 2026. Billed charges act as a strict ceiling on final reimbursement, so charge entry must accurately reflect services rendered.
Humana · Effective Oct 28, 2026High impact
Bevacizumab products
Humana's pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Alymsys, Vegzelma, Jobevne) is dated effective 10/28/2026 for Medicare, Medicaid Kentucky, Medicaid South Carolina, and Medicaid Virginia. It sets prior authorization criteria by indication, including a step-therapy requirement that members have an intolerance or contraindication to Mvasi or Zirabev before Avastin, Alymsys, Jobevne, or Vegzelma oncology requests, plus indication-specific diagnosis and regimen requirements. Billing teams should verify these criteria against the current policy version before scheduling affected infusions.
Humana · Effective Jun 12, 2014Low impact
Sylvant® (siltuximab) (Revised)
This is historical material (published June 2014, revised October 2026) describing Humana's prior authorization policy for Sylvant (siltuximab) for multicentric Castleman's disease. The policy applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid members who meet specific clinical criteria including HIV/HHV-8 negative status and defined laboratory parameters. Initial and renewal approvals are limited to 6 months or as determined through clinical review.
Humana · Effective Jan 1, 2020Medium impact
Kadcyla (ado-trastuzumab emtansine) (Revised)
This is a historical Kadcyla (ado-trastuzumab emtansine) prior authorization policy originally effective January 1, 2020, with a revision dated October 28, 2026. The policy establishes prior authorization requirements for Kadcyla use in metastatic breast cancer and early breast cancer (HER2-positive) for Medicare, Kentucky Medicaid, and South Carolina Medicaid. The billing team must obtain prior authorization before claims are submitted; claims without prior auth will be denied.
Humana · Effective Jun 17, 2020Medium impact
Trodelvy (sacituzumab govitecan-hziy) (Revised)
This is historical material (discovered November 2026, originally published June 2020, most recently revised October 28, 2026). Humana requires prior authorization for Trodelvy (sacituzumab govitecan-hziy) for triple-negative breast cancer and HR-positive HER2-negative breast cancer across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The practice must verify current applicability with Humana before taking action, as policies are updated regularly online.
Humana · Effective Mar 23, 2022Medium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
This is a historical prior authorization policy document for Vyvgart and Vyvgart Hytrulo (efgartigimod alfa products) used to treat generalized myasthenia gravis and chronic inflammatory demyelinating polyneuropathy. The policy was originally effective March 23, 2022, and last revised August 1, 2026. The document specifies prior authorization criteria, specialist supervision requirements, and step-therapy requirements that differ between Medicare and Medicaid. This policy is now over 4 years old from original effective date; verify current applicability with Humana's online policy portal before submitting claims.
Humana · Effective Apr 26, 2023Low impact
Tzield (teplizumab) intravenous solution (Revised)
This is a historical prior authorization policy for Tzield (teplizumab) intravenous solution revised on October 28, 2026 (after the analysis date of November 3, 2026). The policy confirms that Tzield requires prior authorization for Medicare, Medicaid–Kentucky, and Medicaid–South Carolina members with confirmed Stage 2 Type 1 Diabetes. No new billing changes are indicated; this document reaffirms existing prior authorization requirements already in effect since April 26, 2023.
Humana · Effective Jan 1, 2024Medium impact
Zaltrap (ziv-aflibercept) (Revised)
This is a historical policy document (effective 2024-01-01, revised 2026-10-28) that establishes prior authorization requirements for Zaltrap (ziv-aflibercept) in metastatic colorectal cancer. The policy applies to Medicare, Medicaid in Florida, Kentucky, and South Carolina. The billing team should verify this is the current version on Humana's website before taking action, as the discovery date (2026-11-03) does not confirm active applicability.
Humana · Effective Jan 1, 2025High impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (Revised)
This is a historical Humana Medicaid pharmacy prior authorization policy for pembrolizumab products (Keytruda, Keytruda Qlex) that became effective January 1, 2025 and was last revised October 28, 2026. The policy establishes prior authorization requirements across multiple cancer indications with specific clinical criteria, combination therapy requirements, and exclusions (including disease progression on prior anti-PD-1/PD-L1 therapy). The billing team must obtain prior authorization before claims are submitted for these drugs across Florida, Kentucky, and South Carolina Medicaid plans.
Humana · Effective Jan 1, 2026Medium impact
Rituximab products (Revised)
This is a historical Humana Medicaid prior authorization policy for rituximab products (Rituxan, Ruxience, Riabni, Truxima) effective January 1, 2026, revised October 28, 2026, covering Kentucky and South Carolina Medicaid members. The policy requires prior authorization for all listed indications and establishes clinical criteria including mandatory use of generic/biosimilar alternatives (Ruxience or Riabni) first, with branded products (Rituxan or Truxima) approved only if the member has intolerance or contraindication to the alternatives. The policy was discovered on November 3, 2026, but both the effective date (January 1, 2026) and revision date (October 28, 2026) are in the past relative to the analysis date; the practice should verify current applicability with Humana's online policy portal before implementing.
Humana · Effective Oct 28, 2026Medium impact
Revtorpyk® (gedatolisib) (New)
Humana has published a new prior authorization policy for Revtorpyk® (gedatolisib), a breast cancer medication effective October 28, 2026, that applies to Medicare, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid. The practice must obtain prior authorization before dispensing this drug and verify that patients meet five specific clinical criteria, including HR-positive/HER2-negative disease without PIK3CA mutation and prior endocrine therapy failure.
Humana · Effective Oct 28, 2026Low impact
Otarmeni™ (lunsotogene parvec-cwha) intracochlear suspension (New)
Humana has established a new prior authorization policy for Otarmeni™ (lunsotogene parvec-cwha), a gene therapy for OTOF gene mutation–associated hearing loss, effective October 28, 2026. The practice must obtain prior authorization before administering this treatment to affected members in Florida, Kentucky, South Carolina, and Virginia Medicaid and Medicare plans, and must submit documentation confirming the member meets six clinical criteria including severe-to-profound hearing loss, confirmed OTOF variants, preserved outer hair cell function, no prior cochlear implant, and specialist involvement.
UnitedHealthcare · Effective Dec 1, 2026Medium impact
Medicaid: New policy for select embolization procedures
Effective December 1, 2026, UnitedHealthcare Community Plans in Kansas, Kentucky, and New Jersey will implement a new vascular embolization policy and add prior authorization requirements for CPT code 37242. Services previously evaluated under multiple existing policies will now be consolidated under unified clinical criteria for therapeutic vascular embolization procedures.
Humana · Effective Jul 1, 2026High impact
Humana Physician News: Q2 2026
This Q2 2026 Humana newsletter (published April 1, 2026, discovered November 1, 2026) contains multiple effective dates spanning past, ongoing, and future actions. Key changes include: (1) New prior authorization lists effective July 1, 2026, for Medicare Advantage, Dual Eligible SNPs, and Medicaid plans; (2) Medicaid provider-administered medication PAL changes for seven states; (3) PPO members inactive since May 1, 2024, were automatically unpaneled as of March 1, 2026; (4) New claims-based attribution rules for MA products effective April 1, 2026; and (5) Published claims payment policies including a new Paper Claim Administrative Fee. The newsletter emphasizes timely prior authorization submission before services are fully furnished to avoid claim denial and retroactive authorization processing.
Humana · Effective Oct 28, 2026Low impact
Genglycos™ (pariglasgene brecaparvovec-opnr) (New)
Humana has established a new prior authorization policy for Genglycos™ (pariglasgene brecaparvovec-opnr), a gene therapy for glycogen storage disease type Ia (GSDIa), effective October 28, 2026. The policy applies to Medicare and four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia) and requires prior authorization with seven clinical criteria before approval, including patient age ≥8 years, confirmed G6PC gene pathogenic variants, absence of pre-existing AAV8 antibodies, and no prior Genglycos administration. Coverage is limited to a single lifetime dose.
Humana · Identified Oct 28, 2026Medium impact
Beleodaq® (belinostat) (Revised)
This is a historical policy document (original effective date July 24, 2014) that was revised on October 28, 2026. The policy establishes prior authorization requirements for Beleodaq (belinostat) in relapsed or refractory peripheral T-cell lymphoma (PTCL) across Medicare and three state Medicaid programs. The billing team should verify current applicability with Humana rather than treating this as a newly discovered actionable change, since the discovery date (October 28, 2026) matches the revision date but the policy's initial effective date is over 12 years old.
Humana · Effective Oct 19, 2016Medium impact
Clinical Trials Policy (Revised)
This is historical material: a Humana Clinical Trials Pharmacy Policy originally effective 2016-10-19, newly discovered 2026-10-28. The policy governs coverage of routine care and services costs for members enrolled in federally funded or approved clinical trials for cancer or other life-threatening illnesses, with specific eligibility criteria, exclusions, and requirements for trial approval. The revision date of 2026-10-28 reflects recent policy updates; verify current applicability with Humana's online policy portal before applying.
Humana · Effective Jan 1, 2019Low impact
Besponsa™ (inotuzumab ozogamicin) (Revised)
This is a historical policy document (originally effective 2019-01-01, newly discovered 2026-10-28) establishing prior authorization requirements for Besponsa (inotuzumab ozogamicin) in relapsed or refractory B-cell precursor acute lymphoblastic leukemia. The policy applies to Medicare and Medicaid plans in Florida and Kentucky. Billing teams should verify current applicability with Humana's online policy portal rather than treating this discovery as a new mandate.
Humana · Effective Jul 24, 2024Low impact
Beqvez™ intravenous suspension (Revised)
This is a historical policy document (originally effective 2024-07-24, revised 2026-10-28) establishing Humana's prior authorization requirements for Beqvez (fidanacogene elaparvovec-dzkt), a gene therapy for moderate-to-severe hemophilia B. The policy requires prior authorization with specific clinical criteria including age ≥18, factor IX activity ≤2 IU/dL, absence of AAVRh74var neutralizing antibodies, and comprehensive liver/HIV/hepatitis screening. Critical note: Pfizer announced in February 2025 that it will discontinue Beqvez development and commercialization.
Humana · Effective Oct 28, 2026Medium impact
Fayuvi™ (rebisufligene etisparvovec-hopf) (New)
Humana has established a new prior authorization policy effective 2026-10-28 for Fayuvi™ (rebisufligene etisparvovec-hopf), a gene therapy for mucopolysaccharidosis type IIIA in pediatric patients. Coverage requires prior authorization and approval for a single lifetime dose across Medicare, Medicaid (Florida, Kentucky, South Carolina, Virginia). The policy mandates five clinical criteria including preserved neurodevelopmental function, confirmed SGSH enzyme deficiency, and low anti-AAV9 antibody titers.
Humana · Effective Oct 28, 2026Medium impact
Decnupaz (pivekimab sunirine-pvzy) (New)
Humana has established a new prior authorization (PA) policy for Decnupaz (pivekimab sunirine-pvzy), a CD123-directed antibody drug conjugate used to treat blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adult patients. The policy requires PA and restricts coverage to monotherapy use only, effective immediately for Medicare, Medicaid Kentucky, and Medicaid South Carolina plans.
Humana · Effective Oct 28, 2026High impact
Bevacizumab products (New)
Humana has implemented a new Prior Authorization pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) effective immediately. The policy establishes specific clinical criteria and step-therapy requirements for six oncology indications and three ophthalmology indications across Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). Billing staff must verify member eligibility against detailed criteria before processing claims for these drugs.
Humana · Effective Jan 1, 2025Medium impact
Corticotropin Products (Revised)
This is a historical Humana prior authorization policy for corticotropin products (Acthar Gel, Cortrophin Gel) that became effective January 1, 2025 and was last revised March 25, 2026. The policy establishes prior authorization requirements for four indications: West Syndrome in infants under 2 years, acute MS exacerbations, acute exacerbations of rheumatic/collagen/ophthalmic diseases and nephrotic syndrome, and symptomatic sarcoidosis. Billing teams should verify current applicability with Humana, as the source advises checking online for the most up-to-date version before using this policy.
Humana · Effective Jan 1, 2026Medium impact
Ocrevus® (ocrelizumab) & Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq) (Revised)
This is a historical policy document (source published 2026-01-01, newly discovered 2026-10-24) establishing Humana's prior authorization requirements for Ocrevus and Ocrevus Zunovo in the treatment of multiple sclerosis across Medicare and three state Medicaid programs. The policy, effective January 1, 2026 with a revision dated June 24, 2026, has already been in effect for over nine months. The billing team should verify current applicability by consulting Humana's online policy portal, as this document may have been superseded.
Humana · Effective Jan 1, 2026High impact
Briumvi™ (ublituximab) (Revised)
This is a historical policy document (published January 1, 2026, discovered October 24, 2026) establishing Humana's prior authorization requirements for Briumvi (ublituximab) across Medicare Part B, Medicare Part D, and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy requires step-therapy documentation of prior MS medication trials for Medicare beneficiaries, with exemptions for Medicare Part B continuation therapy and all Medicaid requests. Verify current applicability with Humana before implementing billing changes, as this revision (dated February 25, 2026) may have been superseded.
Humana · Effective Jan 1, 2017Low impact
Quantity Limitation (Revised)
This is a historical policy document from January 1, 2017 that was recently discovered (October 21, 2026). It establishes Humana's framework for pharmacy quantity limitations across Medicare and multiple state Medicaid programs. The policy permits quantity limits based on FDA-approved dosing, medical literature, and treatment guidelines, with exceptions available for dosage titration, compendia-supported dosages, failed trials, or individual member characteristics. The most recent revision is October 21, 2026, but no new effective date or changes are stated in this revision—verify current applicability with Humana's online policy portal.
Humana · Effective Jun 3, 2020Low impact
Non-FDA Approved Medications (Revised)
This is historical material from a Humana Medicaid pharmacy policy originally effective June 3, 2020, revised October 21, 2026. The policy establishes that non-FDA approved medications are excluded from Humana formularies unless reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. Coverage for approved non-FDA medications is limited to the plan year duration. No new actionable changes are indicated; verify current applicability with Humana before applying this guidance.
Humana · Effective Jan 1, 2020Medium impact
Crysvita® (burosumab) (Revised)
This is a historical Crysvita (burosumab) prior authorization policy for X-Linked Hypophosphatemia (XLH) and Tumor-Induced Osteomalacia (TIO) that was originally effective January 1, 2020 and most recently revised February 25, 2026. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and outlines specific clinical criteria, diagnostic requirements, contraindications, and age-based laboratory thresholds for coverage. The billing team should verify current applicability with Humana before applying this policy, as it was newly discovered on October 17, 2026, despite its 2020 original effective date.
Humana · Effective Jun 16, 2021Low impact
Amondys 45 (casimersen) (Revised)
This is historical material: a Humana prior authorization policy for Amondys 45 (casimersen) for Duchenne Muscular Dystrophy, originally effective June 16, 2021, with a revision dated December 17, 2025. The policy establishes prior authorization requirements for this intravenous antisense oligonucleotide therapy, including six initial approval criteria and one renewal criterion based on functional improvement or maintenance. The billing team should verify current applicability through Humana's online policy portal rather than relying on this newly discovered source.
Humana · Effective Jan 1, 2022Medium impact
Viltepso™ (viltolarsen) (Revised)
This is a historical Humana prior authorization policy for Viltepso (viltolarsen), a Duchenne Muscular Dystrophy treatment, originally effective January 1, 2022 and most recently revised December 17, 2025. The policy was newly discovered on October 17, 2026, but represents established coverage criteria for Medicare and Medicaid (Kentucky and South Carolina) members. The billing team should verify current applicability with Humana before applying these criteria, as the policy document itself instructs users to check online for the most up-to-date version.
Humana · Effective Jan 1, 2022Medium impact
Exondys 51 (eteplirsen) (Revised)
This is a historical policy document (originally effective 2022-01-01, most recently revised 2025-12-17) for Exondys 51 (eteplirsen) coverage under Humana Medicare, Medicaid-Kentucky, and Medicaid-South Carolina plans. The policy requires prior authorization for this Duchenne Muscular Dystrophy treatment and specifies six initial criteria and one renewal criterion for coverage eligibility. The billing team should verify current applicability with Humana before submitting claims, as this document was newly discovered on the analysis date but represents established policy.
Humana · Effective Feb 23, 2022Low impact
Xipere® (triamcinolone acetonide) (Revised)
This is historical material: a Humana pharmacy prior authorization policy for Xipere® (triamcinolone acetonide) for macular edema associated with uveitis, originally effective February 23, 2022, and last revised July 22, 2026. The policy is already in effect. Billing teams should verify current applicability with Humana's online policy portal and confirm whether this guidance remains active for their contracted plans.

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Saphnelo® (Anifrolumab-Fnia)

Pasatru™ (Garetosmab-Grts)

Omalizumab

Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease

Maximum Dosage and Frequency

Ilaris ® (Canakinumab)

Hereditary Angioedema (HAE), Treatment and Prophylaxis

Genglycos ™ (Pariglasgene Brecaparvovec-Opnr)

FcRn Blockers

Denosumab

Whole Exome and Whole Genome Sequencing (Non-Oncology Conditions) (for Kentucky Only)

Video Electroencephalographic (vEEG) Monitoring and Recording (for Kentucky Only)

Vascular Embolization: Select Procedures (for Kentucky Only)

Treatment of Temporomandibular Joint Disorders (for Kentucky Only)

Surgery of the Elbow (for Kentucky Only)

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Kentucky Only)

Molecular Oncology Testing for Hematologic Cancer Diagnosis, Prognosis, and Treatment Decisions (for Kentucky Only)

Bariatric Surgery (for Kentucky Only)

Update to Inpatient Hospital Reimbursement - Effective October 1, 2026

Bevacizumab products

Sylvant® (siltuximab) (Revised)

Kadcyla (ado-trastuzumab emtansine) (Revised)

Trodelvy (sacituzumab govitecan-hziy) (Revised)

Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)

Tzield (teplizumab) intravenous solution (Revised)

Zaltrap (ziv-aflibercept) (Revised)

Pembrolizumab products (Keytruda, Keytruda Qlex) (Revised)

Rituximab products (Revised)

Revtorpyk® (gedatolisib) (New)

Otarmeni™ (lunsotogene parvec-cwha) intracochlear suspension (New)

Medicaid: New policy for select embolization procedures

Humana Physician News: Q2 2026

Genglycos™ (pariglasgene brecaparvovec-opnr) (New)

Beleodaq® (belinostat) (Revised)

Clinical Trials Policy (Revised)

Besponsa™ (inotuzumab ozogamicin) (Revised)

Beqvez™ intravenous suspension (Revised)

Fayuvi™ (rebisufligene etisparvovec-hopf) (New)

Decnupaz (pivekimab sunirine-pvzy) (New)

Bevacizumab products (New)

Corticotropin Products (Revised)

Ocrevus® (ocrelizumab) & Ocrevus Zunovo™ (ocrelizumab and hyaluronidase-ocsq) (Revised)

Briumvi™ (ublituximab) (Revised)

Quantity Limitation (Revised)

Non-FDA Approved Medications (Revised)

Crysvita® (burosumab) (Revised)

Amondys 45 (casimersen) (Revised)

Viltepso™ (viltolarsen) (Revised)

Exondys 51 (eteplirsen) (Revised)

Xipere® (triamcinolone acetonide) (Revised)