All Insurance Policy Changes (Page 159)

Continuing from page 158. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Smart Maintenance Dose (Revised)
Humana·Effective Sep 24, 2025
Humana Medicare Advantage is implementing Smart Maintenance Dose (SMD) point-of-sale edits for specialty drugs with induction/maintenance phases. Claims for dosages exceeding the maintenance dose will be held for clinical review when prior loading dose evidence exists. Providers must now submit clinical and dosing rationale to justify higher-than-maintenance doses; approval is case-by-case through end of plan year.
Low impact
Turalio® (pexidartinib) (Revised)
Humana·Effective Dec 17, 2025
Humana Medicare Advantage has revised its prior authorization policy for Turalio® (pexidartinib) effective December 17, 2025. The policy maintains coverage for symptomatic tenosynovial giant cell tumor (TGCT) with four strict approval criteria: confirmed diagnosis, severe morbidity/functional limitations, disease not amenable to surgery, and monotherapy use only. Prior authorization is required with 6-month initial and renewal approval periods.
Medium impact
Duloxetine Containing Products (Revised)
Humana·Effective Sep 24, 2025
Humana revised its prior authorization policy for Duloxetine-containing products (Drizalma Sprinkle) effective September 24, 2025. The policy requires prior authorization for duloxetine use in Medicare Advantage members with MDD, GAD, or DPNP (only after failure/intolerance with venlafaxine AND lower-dose duloxetine), and for chronic musculoskeletal pain or fibromyalgia (after failure/intolerance with duloxetine). Approval is granted for the plan year duration for both initial and renewal requests.
Medium impact
Rozlytrek™ (entrectinib) (Revised)
Humana·Effective May 27, 2026
Humana has revised its Rozlytrek (entrectinib) pharmacy coverage policy effective May 27, 2026. This is a prior authorization policy for Medicare Advantage members with metastatic/recurrent ROS1-positive NSCLC or metastatic solid tumors with NTRK gene fusion. The policy clarifies approval criteria and duration requirements for this targeted cancer therapy.
Medium impact
Baclofen Products (Fleqsuvy™, baclofen oral solution, baclofen oral suspension, Ozobax™, Lyvispah™) (Revised)
Humana·Effective Apr 24, 2024
Humana revised its prior authorization policy for baclofen oral products (Fleqsuvy, Ozobax, Lyvispah, and generic baclofen solutions/suspensions) effective April 24, 2024. The policy maintains prior authorization requirements for patients age 12+ with spasticity, muscle spasm, myoclonus, or muscle rigidity from multiple sclerosis or spinal cord injury/disease who have failed or are intolerant to baclofen tablets and tizanidine tablets. No specific coverage changes are documented in this revision, but the policy has been formally reviewed and updated.
Medium impact
Asparlas™ (calaspargase pegol-mknl) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Asparlas (calaspargase pegol-mknl) pharmacy coverage policy effective October 22, 2025. This is a prior authorization policy for a pegylated L-asparaginase used in pediatric/young adult ALL treatment (ages ≤21 years). The policy requires prior auth with specific clinical criteria, exclusions for serious adverse history, and 6-month approval/renewal cycles. Billing teams must verify patient age, ALL diagnosis, multi-agent chemotherapy regimen use, and absence of contraindications before claim submission.
Medium impact
Zolinza® (vorinostat) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Medicare Advantage prior authorization policy for Zolinza® (vorinostat), a histone deacetylase inhibitor used to treat cutaneous T-cell lymphoma (CTCL). The policy was last revised on January 28, 2026 (1 day old). The policy requires prior authorization for Zolinza and specifies that coverage applies only to patients with progressive, persistent, or recurrent CTCL disease or those receiving it as primary/adjuvant therapy. Treatment may continue as long as there is no disease progression or unacceptable toxicity.
Medium impact
Xepi (ozenoxacin) topical cream (Revised)
Humana·Effective Dec 18, 2024
Humana revised its Xepi (ozenoxacin) topical cream prior authorization policy effective December 18, 2024. The policy maintains prior authorization requirements for impetigo treatment and clarifies that Xepi requires documentation of previous treatment failure, contraindication, or intolerance to mupirocin within the past 12 months, with age requirement of 2+ months. This is a policy revision (not a new policy) affecting Medicare Advantage and Commercial plan members.
Medium impact
Vimovo® (naproxen-esomeprazole magnesium) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage updated the Vimovo (naproxen-esomeprazole magnesium) prior authorization policy effective January 28, 2026. The policy requires prior authorization for all Vimovo prescriptions and mandates that patients must have prior treatment with two combinations of prescription-strength NSAID plus PPI before approval. Patients must be 12+ years old, weigh at least 38 kg, and have one of four specified arthritis diagnoses.
Medium impact
Valchlor® (mechlorethamine) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage updated its Valchlor (mechlorethamine) prior authorization policy effective January 28, 2026. The revision reinforces existing coverage criteria for fungoides-type cutaneous T-cell lymphoma treatment, with mandatory prior authorization required. Key clinical criteria include documented fungoides-type CTCL diagnosis and prior skin-directed therapy or use as primary treatment. Claims will be denied without prior authorization.
Medium impact
Topical Antifungals (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage has revised its Topical Antifungals pharmacy coverage policy, implementing a step therapy requirement effective January 1, 2020 (with policy revision dated July 23, 2025). Members must have documented previous treatment failure, contraindication, or intolerance to at least two first-line topical antifungals (clotrimazole cream, ciclopirox, or ketoconazole cream) within the past 12 months before coverage is approved for branded agents like Exelderm, Luzu, Naftin, or sulconazole products.
Medium impact
Tibsovo® (ivosidenib) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage has revised its Tibsovo® (ivosidenib) prior authorization policy effective October 22, 2025. This is a pharmacy coverage policy for an IDH1 inhibitor used in treating acute myeloid leukemia (AML), myelodysplastic syndromes (MDS), and cholangiocarcinoma. The policy maintains prior authorization requirements across four disease indications with specific clinical criteria, including documented IDH1 mutation status and disease stage requirements.
High impact
Temodar (temozolomide) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Medicare Advantage prior authorization policy for Temodar (temozolomide) effective January 1, 2020, with the most recent revision dated December 17, 2025. The policy outlines specific clinical criteria and approved indications for temozolomide coverage across multiple cancer types including glioblastoma, anaplastic gliomas, low-grade gliomas, Ewing's sarcoma, melanoma, neuroendocrine tumors, mycosis fungoides/Sezary syndrome, CNS lymphoma, and soft tissue sarcoma. All requests require prior authorization and must meet defined clinical criteria; claims without approval will be denied.
High impact
Spritam® (levetiracetam) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage revised its Spritam (levetiracetam) pharmacy coverage policy effective October 22, 2025, implementing a step therapy requirement. Members must have prior therapy with levetiracetam AND at least one alternative anticonvulsant (lamotrigine, carbamazepine, topiramate, divalproex, or phenytoin) before Spritam approval. This is a gatekeeping requirement that will affect prescription authorization workflows.
Medium impact
Serostim® (somatropin) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage revised its Serostim (somatropin) prior authorization policy effective January 28, 2026. The policy maintains existing coverage criteria for HIV-associated wasting/cachexia treatment but clarifies diagnostic thresholds, requires concomitant antiretroviral therapy, and mandates prior treatment/contraindication/intolerance with Marinol or Megace. All requests require prior authorization, with approvals granted for plan year durations.
Medium impact
Ruxolitinib products (Jakafi, Jakafi XR) (Revised)
Humana·Effective Jun 24, 2026
Humana Medicare Advantage has revised its prior authorization policy for Ruxolitinib products (Jakafi, Jakafi XR) effective June 24, 2026. The policy maintains coverage for four indications: myelofibrosis (intermediate/high-risk per IPSS), polycythemia vera (after hydroxyurea failure/intolerance), steroid-refractory acute GVHD, and chronic GVHD (after prior systemic therapy failure). Key requirement: all members with prior disease progression on ruxolitinib are excluded from coverage.
Medium impact
Rozerem® (ramelteon) (Revised)
Humana·Effective Jan 1, 2020
Humana Medicare Advantage updated its Rozerem® (ramelteon) pharmacy coverage policy, effective January 1, 2020, with a revision date of March 25, 2026. The policy implements a step therapy requirement: members must have previous treatment failure, documented contraindication, or documented intolerance to Belsomra or trazodone tablet before Rozerem is approved. Coverage is approved for plan year duration on both initial and renewal requests.
High impact
Prolia® (denosumab) and biosimilars (Revised)
Humana·Effective Jan 1, 2020
Humana revised its Prolia (denosumab) and biosimilars prior authorization policy effective January 1, 2020, with updates as of March 25, 2026. The policy now includes eight denosumab products (Prolia, Jubbonti, Conexxence, Stoboclo, Bildyos, Ospomyv, Enoby, Bosaya) across five indications: glucocorticoid-induced osteoporosis, osteoporosis, nonmetastatic prostate cancer, hormone-receptor-positive breast cancer, and postmenopausal osteopenia. A critical step-therapy requirement mandates that members requesting biosimilar products (all except Prolia and Jubbonti) must have prior treatment with or documented intolerance to Prolia or Jubbonti, except for Medicare Part B continuation therapy within 365 days.
Medium impact
Previous Treatment/Prior Therapy/Trial (Revised)
Humana·Effective Jan 1, 2020
Humana revised its Prior Therapy/Previous Treatment/Trial guidance policy (effective 1/1/2020, revised 10/22/2025) clarifying that a SINGLE pharmacy claim can demonstrate prerequisite therapy requirements across Medicare and multiple Medicaid state plans (FL, SC, IN, OK, VA). A single claim—typically 28-30 days but potentially shorter for appropriate drug classes like antibiotics/analgesics—now satisfies step therapy requirements unless a specific shorter timeframe is defined in drug-specific clinical policies. Prescriber documentation of medication failure is also now explicitly acceptable. This is a GUIDANCE policy affecting claim approval workflows.
Medium impact
Portrazza (necitumumab) (Revised)
Humana·Effective Jan 1, 2020
Humana has revised its Portrazza (necitumumab) prior authorization policy for Medicare Advantage members with metastatic squamous non-small cell lung cancer. The policy maintains first-line treatment coverage in combination with gemcitabine and cisplatin, but includes a critical clinical note that Portrazza has been removed from NCCN guidelines and carries Black Box Warnings for cardiopulmonary arrest and hypomagnesemia. Billing teams must ensure prior authorization is obtained before claims submission and verify member eligibility against the three coverage criteria.
Medium impact
Perjeta (pertuzumab) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Perjeta (pertuzumab) prior authorization policy effective January 1, 2020, with the most recent revision dated January 28, 2026. The policy covers HER2-positive breast cancer treatment in three scenarios: neoadjuvant therapy for locally advanced/inflammatory/early-stage disease, adjuvant therapy for early-stage high-risk disease, and metastatic disease. Key requirement: treatment cannot exceed 52 weeks or 18 cycles. All uses require prior authorization and specific HER2 testing confirmation (IHC 3+ or IHC 2+/ISH positive).
Medium impact
Oxtellar XR® (oxcarbazepine extended release) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its pharmacy coverage policy for Oxtellar XR (oxcarbazepine extended release) effective October 22, 2025. This is a step therapy policy requiring members to have prior therapy with or intolerance to immediate-release oxcarbazepine (generic Trileptal) before Oxtellar XR will be covered. The policy applies to Medicare Advantage members with seizure disorders and specifies important clinical considerations including monitoring for hyponatremia, serious dermatological reactions, and suicidal ideation.
Medium impact
Oral Acne Antibiotics (Revised)
Humana·Effective Jan 1, 2020
This revised Humana Medicare Advantage policy establishes a Step Therapy requirement for oral acne antibiotics (minocycline extended-release formulations, Solodyn, Seysara, and Ximino). Members must have previous treatment or documented intolerance with generic immediate-release minocycline before extended-release formulations are covered. The policy was last revised on July 23, 2025 (1 day old) and is effective January 1, 2020.
Medium impact
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (Revised)
Humana·Effective Aug 27, 2025
Humana revised its Ophthalmic NSAID coverage policy for Medicare effective August 27, 2025. This is a step therapy policy requiring members to have failed or have contraindications/intolerances to Ilevro AND one additional NSAID (diclofenac, ketorolac, or flurbiprofen) before coverage approval for branded ophthalmic NSAIDs (Acular, Acular LS, Acuvail, BromSite, Nevanac, Prolensa, bromfenac). The policy maintains plan year approval duration for both initial and renewal requests.
Medium impact
Non-Preferred Exceptions (Revised)
Humana·Effective Aug 6, 2025
This is a refreshed guidance policy (revised August 6, 2025) clarifying Humana's non-preferred pharmacy exception procedures for Medicaid members in Florida, South Carolina, and Virginia. The policy establishes a 24-hour decision timeframe for non-preferred drug exception requests submitted via phone, fax, or electronic prior authorization, with approved exceptions valid for up to one year. No substantive changes from the original January 1, 2020 effective date are documented—this appears to be a routine policy republication.

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Archive by year

2023 2024 2025 2026

Smart Maintenance Dose (Revised)

Turalio® (pexidartinib) (Revised)

Duloxetine Containing Products (Revised)

Rozlytrek™ (entrectinib) (Revised)

Baclofen Products (Fleqsuvy™, baclofen oral solution, baclofen oral suspension, Ozobax™, Lyvispah™) (Revised)

Asparlas™ (calaspargase pegol-mknl) (Revised)

Zolinza® (vorinostat) (Revised)

Xepi (ozenoxacin) topical cream (Revised)

Vimovo® (naproxen-esomeprazole magnesium) (Revised)

Valchlor® (mechlorethamine) (Revised)

Topical Antifungals (Revised)

Tibsovo® (ivosidenib) (Revised)

Temodar (temozolomide) (Revised)

Spritam® (levetiracetam) (Revised)

Serostim® (somatropin) (Revised)

Ruxolitinib products (Jakafi, Jakafi XR) (Revised)

Rozerem® (ramelteon) (Revised)

Prolia® (denosumab) and biosimilars (Revised)

Previous Treatment/Prior Therapy/Trial (Revised)

Portrazza (necitumumab) (Revised)

Perjeta (pertuzumab) (Revised)

Oxtellar XR® (oxcarbazepine extended release) (Revised)

Oral Acne Antibiotics (Revised)

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (Revised)

Non-Preferred Exceptions (Revised)