All Insurance Policy Changes (Page 158)

Continuing from page 157. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Nitisinone Products (Revised)
Humana·Effective Feb 28, 2024
Humana revised its prior authorization policy for nitisinone products (Orfadin capsule/suspension and generic nitisinone capsules) effective February 28, 2024. The policy now requires prior authorization for all nitisinone products used to treat hereditary tyrosinemia type 1 (HT-1), with three approval criteria: confirmed HT-1 diagnosis, plasma tyrosine level below 500 micromol/L on a restricted diet, and previous treatment or documented intolerance to generic nitisinone capsules. Approvals are granted for plan year durations or as determined through clinical review.
Medium impact
Namzaric® (memantine and donepezil extended release) (Revised)
Humana·Effective Jan 24, 2024
Humana revised its Namzaric (memantine/donepezil) prior authorization policy effective January 24, 2024. The policy requires prior authorization for Namzaric coverage and mandates that members have confirmed moderate-to-severe Alzheimer's dementia AND prior treatment with both memantine AND donepezil individually before approval. Billing teams must verify both criteria are documented before submitting claims to avoid denial.
Low impact
Memantine Products (Revised)
Humana·Effective Jan 1, 2019
This is a routine policy revision for Humana's Memantine Products pharmacy coverage (revised November 26, 2025). The policy maintains prior authorization requirements for memantine oral solutions, tablets, and extended-release capsules used to treat moderate-to-severe Alzheimer's disease. The primary approval criterion remains unchanged: members must be over 26 years old, OR if 26 or younger, must not have a diagnosis of Autism or Atypical Autism (PDD). No substantive coverage changes are documented in this revision.
Medium impact
Limited Day Supply (Revised)
Humana·Effective Jan 1, 2019
Humana revised its Limited Day Supply policy (effective January 1, 2019, with revision date December 24, 2025) to clarify pharmacy coverage limitations across Medicare, LINET, and four Medicaid state programs (South Carolina, Indiana, Oklahoma, Virginia). The policy restricts day supply for specialty drugs (30-day maximum), opioids, benzodiazepines, and approved non-formulary exceptions to prevent waste, abuse, and overdose risk. This is guidance documentation with no new billing codes but requires billing teams to enforce day supply limits at the point of claim adjudication.
High impact
Intravenous tocilizumab products (Revised)
Humana·Effective Jan 1, 2019
Humana Medicare Advantage has revised its prior authorization policy for intravenous tocilizumab products (Actemra, Tyenne, Tofidence, Avtozma) effective January 1, 2019, with the most recent revision dated October 22, 2025. The policy establishes specific clinical criteria and exclusions for coverage across five indications: rheumatoid arthritis, systemic juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, cytokine release syndrome, and giant cell arteritis. Billing teams must implement prior authorization requirements and enforce step therapy protocols requiring documented prior therapy or contraindications with specific biologics before tocilizumab approval.
Medium impact
Gattex® (teduglutide) (Revised)
Humana·Effective Jan 1, 2019
Humana updated its Gattex (teduglutide) prior authorization policy for Medicaid beneficiaries in Kentucky, effective January 1, 2019, with a revision date of August 27, 2025. The policy requires prior authorization for Gattex 30-Vial and One-Vial subcutaneous kits for Short Bowel Syndrome patients dependent on parenteral support, with initial approval for 3 months and renewal based on demonstrated decrease in parenteral support volume. Billing teams must ensure claims for this medication include documentation of Short Bowel Syndrome diagnosis, parenteral dependency, absence of active GI malignancy, and absence of biliary/pancreatic disease.
Medium impact
GLP-1 Analogs (Revised)
Humana·Effective Mar 27, 2024
Humana Medicare Advantage revised its GLP-1 Analog step therapy policy on March 27, 2024. The policy requires members to have failed or been intolerant to at least two of six specified GLP-1 analogs (Victoza, Trulicity, Ozempic, Bydureon, Rybelsus, or Mounjaro) before coverage of Byetta or generic exenatide is approved. This step therapy requirement remains in effect and applies to both Byetta subcutaneous pen injectors and exenatide subcutaneous pen injectors.
Medium impact
Formulary Tier Exception (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Medicare Part D Formulary Tier Exception policy (effective 1/1/2019, revised 2/25/2026) to clarify the process for approving non-preferred drugs at lower cost-sharing tiers. Key clarification: when a tier exception is approved, the member pays the cost-sharing of the LOWEST applicable tier for that drug class (brand-to-brand, biologic-to-biologic, or generic-to-generic/brand), not the higher tier. Specialty tier drugs remain ineligible for tier exceptions. Billing teams must ensure prior authorization requests include physician supporting statements documenting medical necessity.
Medium impact
Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Erwinase (asparaginase Erwinia chrysanthemi) prior authorization policy effective September 24, 2025. The policy maintains coverage for ALL patients with Grade 2-4 hypersensitivity to prior Oncaspar treatment, requires prior authorization, and reinforces four specific exclusion criteria (serious pancreatitis, thrombosis, hemorrhagic events, or disease progression with prior asparaginase therapy). Approval duration remains 6 months for both initial and renewal requests.
High impact
EpiPen® and EpiPen Jr® (epinephrine) (Revised)
Humana·Effective Jan 24, 2024
Humana revised its EpiPen/EpiPen Jr pharmacy coverage policy effective January 24, 2024, implementing a step therapy requirement. Members must have prior treatment with generic epinephrine auto-injectors or Symjepi before coverage of brand-name EpiPen products is approved. This is a coverage restriction that will require prior authorization for affected claims.
Medium impact
Envarsus XR® (tacrolimus extended-release) (Revised)
Humana·Effective Jan 1, 2019
This is a revised Humana Medicare Advantage prior authorization policy for Envarsus XR (tacrolimus extended-release) effective January 1, 2019, with the most recent revision dated February 25, 2026. The policy maintains existing coverage criteria requiring patients to have received a kidney transplant, be using the medication for organ rejection prophylaxis, and be on concurrent immunosuppressive therapy. No substantive changes to coverage criteria are indicated in this revision; however, the policy has been formally reviewed and reissued, so billing teams must verify this is the current version being used for all authorization requests.
Low impact
Cayston® (aztreonam inhalation solution) (Revised)
Humana·Effective Jan 1, 2019
Humana updated its Cayston® (aztreonam inhalation solution) prior authorization policy effective January 1, 2019, with a revision date of December 17, 2025. This is a Medicare Advantage pharmacy coverage policy requiring prior authorization for Cayston in cystic fibrosis patients colonized with Pseudomonas aeruginosa. The policy maintains three approval criteria and two exclusionary criteria, with no apparent changes to clinical requirements from the original effective date.
Medium impact
Biguanide Agents (Revised)
Humana·Effective Jan 1, 2019
Humana Medicare Advantage updated its Biguanide Agents (metformin) pharmacy coverage policy effective January 1, 2019, with a revision dated October 22, 2025. This is a step therapy policy requiring members to have at least 3 months of prior treatment or documented intolerance to metformin IR (500mg, 850mg, or 1000mg) or metformin ER before approval for Glumetza, metformin 625mg, or other metformin ER formulations. Approvals are granted for plan year durations or as determined through clinical review.
Medium impact
Besponsa™ (inotuzumab ozogamicin) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Besponsa (inotuzumab ozogamicin) pharmacy coverage policy, effective November 26, 2025. This is a revision to an existing prior authorization policy for relapsed/refractory B-cell precursor acute lymphoblastic leukemia (ALL) treatment. The policy requires prior authorization for all Besponsa use and mandates strict clinical criteria including CD22 blast confirmation and monotherapy use. Claims submitted without meeting all four approval criteria or containing the disease progression exclusion will be denied.
High impact
Benzodiazepine Limited Days' Supply (Revised)
Humana·Effective Apr 30, 2025
Humana has revised its benzodiazepine limited days' supply policy, effective April 30, 2025. All benzodiazepine medications across Medicare, LINET, Puerto Rico, and three state Medicaid programs (South Carolina, Oklahoma, Virginia) are now subject to strict day supply limits: 30 days for Medicare/LINET/SC/OK Medicaid, 31 days for Medicare/LINET LTC residents, and 34 days for Virginia Medicaid. This policy aims to reduce overdose risk and prevent medication waste, and applies regardless of tier or formulary coverage.
Medium impact
Bavencio® (avelumab) (Revised)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage revised its Bavencio (avelumab) prior authorization policy effective July 23, 2025. The policy maintains coverage for four oncology indications (renal cell carcinoma, Merkel cell carcinoma in adults and pediatrics 12+, and urothelial cancer) with specific treatment line requirements and exclusions. Key exclusion: members with disease progression on/after PD-1/PD-L1 therapy are not approved. Prior auth approval duration remains 6 months initial and renewal.
Medium impact
Antipsychotic Utilization Program (Revised)
Humana·Effective Jun 10, 2026
Humana revised its Antipsychotic Utilization Program (effective June 10, 2026) to strengthen prior authorization requirements for atypical and typical antipsychotic medications in members with dementia. The policy now requires prior auth when members 65+ with dementia receive a new antipsychotic prescription without compendia-supported diagnoses (schizophrenia, bipolar disorder, Huntington's disease, Tourette's syndrome) or documented dangerous/severe dementia-related psychosis. This aligns with Beers Criteria guidance and CMS compliance efforts to reduce inappropriate antipsychotic use in elderly patients.
Medium impact
Tolsura (itraconazole) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage has revised its prior authorization policy for Tolsura (itraconazole) effective October 22, 2025. The policy maintains three covered indications (aspergillosis, blastomycosis, histoplasmosis) with specific criteria requiring failure or intolerance to alternative antifungals, excludes onychomycosis treatment, and approves coverage for 6-month periods with clinical review. Key safety warnings regarding CHF, hepatotoxicity, cardiac dysrhythmias, and extensive drug interactions with CYP3A4 and CYP2D6 metabolizers are emphasized.
High impact
Drug Management Program-Opioid Program (Revised)
Humana·Effective Jul 23, 2025
Humana revised its Drug Management Program-Opioid Program (effective July 23, 2025) to strengthen beneficiary-level edits for at-risk opioid and benzodiazepine users on Medicare. The policy now includes refined criteria for triggering reviews (MME thresholds, prescriber/pharmacy counts, overdose history), specific exclusions (cancer, hospice, palliative care, long-term care, assisted living, sickle cell), and clear procedures for adjustment or removal of restrictions. Billing teams must implement these changes to ensure compliant pharmacy claim processing and avoid claim denials for members subject to quantity limits or prescriber/pharmacy restrictions.
Medium impact
Short Acting Beta Agonists (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage has revised its Short Acting Beta Agonist (SABA) inhaler coverage policy, effective May 27, 2026. The policy implements step therapy requiring members to have prior treatment with generic albuterol HFA or Ventolin HFA before coverage of branded alternatives (ProAir RespiClick, ProAir Digihaler, Xopenex HFA, levalbuterol HFA). This is a prior authorization requirement that affects pharmacy claims for these specific SABA inhalers.
Medium impact
Vitrakvi (larotrectinib) (Revised)
Humana·Effective Aug 27, 2025
Humana updated its Vitrakvi (larotrectinib) pharmacy coverage policy for Medicare Advantage members on August 27, 2025. The policy maintains prior authorization requirements for this TRK inhibitor used to treat advanced/metastatic NTRK gene fusion-positive solid tumors. Key criteria remain: confirmed NTRK gene fusion without resistance mutation, advanced/metastatic disease or surgical inoperability, and no satisfactory alternative treatment options. The revision appears to be a routine update with prescribing information current as of April 2025.
High impact
Levoleucovorin products (Revised)
Humana·Effective Sep 24, 2025
This is a revised Humana prior authorization policy for levoleucovorin products (Khapzory, Fusilev, generic levoleucovorin) effective immediately for Medicare and Medicaid plans in Kentucky, South Carolina, and Virginia. The policy clarifies coverage criteria for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer. All requests require prior authorization and documented failure or intolerance of leucovorin calcium before levoleucovorin approval.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Gamifant (emapalumab-lzsg) prior authorization policy effective September 24, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains coverage for primary HLH and HLH/MAS in Still's disease with specific diagnostic criteria, stem cell transplant candidacy requirements, and mandatory dexamethasone co-administration. No coverage expansion or restriction changes are documented in this revision.
Low impact
Cablivi® (caplacizumab-yhdp) (Revised)
Humana·Effective Mar 25, 2026
Humana updated its Cablivi (caplacizumab-yhdp) prior authorization policy effective March 25, 2026. The policy reinforces coverage criteria for this rare disease treatment (acquired thrombotic thrombocytopenic purpura) requiring diagnosis confirmation, concurrent or post-plasma exchange therapy, and limits continuation to members with ≤2 recurrences. Initial and renewal approvals are both 3-month intervals.
High impact
Medical Necessity Determinations (Revised)
Humana·Effective Oct 15, 2025
Humana has revised its Medical Necessity Determinations policy for Medicaid in Florida (effective October 15, 2025). This guidance clarifies the five-point criteria required to establish medical necessity for pharmacy and medical services under Florida Medicaid rules 59G-1.010, including requirements that services be covered benefits, meet state/federal regulations, be medically acceptable, align with professional standards, and represent the most conservative available treatment. Billing teams must ensure all prior authorization requests and claim submissions document compliance with these specific criteria.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 158) | PolicyChanges.app

Nitisinone Products (Revised)

Namzaric® (memantine and donepezil extended release) (Revised)

Memantine Products (Revised)

Limited Day Supply (Revised)

Intravenous tocilizumab products (Revised)

Gattex® (teduglutide) (Revised)

GLP-1 Analogs (Revised)

Formulary Tier Exception (Revised)

Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)

EpiPen® and EpiPen Jr® (epinephrine) (Revised)

Envarsus XR® (tacrolimus extended-release) (Revised)

Cayston® (aztreonam inhalation solution) (Revised)

Biguanide Agents (Revised)

Besponsa™ (inotuzumab ozogamicin) (Revised)

Benzodiazepine Limited Days' Supply (Revised)

Bavencio® (avelumab) (Revised)

Antipsychotic Utilization Program (Revised)

Tolsura (itraconazole) (Revised)

Drug Management Program-Opioid Program (Revised)

Short Acting Beta Agonists (Revised)

Vitrakvi (larotrectinib) (Revised)

Levoleucovorin products (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Cablivi® (caplacizumab-yhdp) (Revised)

Medical Necessity Determinations (Revised)