All Insurance Policy Changes (Page 161)

Continuing from page 160. 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
Blincyto® (blinatumomab) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Blincyto (blinatumomab) prior authorization policy effective January 1, 2020, with updates as of August 27, 2025. The policy covers four treatment indications for B-cell acute lymphoblastic leukemia across Medicare and Medicaid (Kentucky and South Carolina). All Blincyto claims require prior authorization with approval valid for the plan year or as determined through clinical review.
Medium impact
Arikayce® (liposomal amikacin for inhalation) (Revised)
Humana·Effective Feb 25, 2026
Humana's Medicare Advantage plan has revised its prior authorization policy for Arikayce (liposomal amikacin for inhalation), effective February 25, 2026. The policy maintains strict coverage criteria requiring MAC lung disease diagnosis, failure of 6+ months of multi-drug therapy with negative sputum cultures, limited alternative options, and use as part of a multi-drug regimen. Arikayce cannot be used as monotherapy, for non-MAC infections, or continued beyond 6 months if sputum cultures do not convert to negative.
Medium impact
Apadaz® (benzhydrocodone and acetaminophen) (Revised)
Humana·Effective Aug 28, 2024
Humana updated its Apadaz (benzhydrocodone-acetaminophen) prior authorization policy on August 28, 2024. The policy requires prior authorization for this opioid analgesic combination and mandates that members meet strict criteria: acute pain diagnosis, therapy duration ≤14 days, age ≥18 years, and documented inadequate response to or intolerance of specific alternative opioids. Key exclusions include significant respiratory depression, severe unmonitored asthma, and GI obstruction. Initial approval is issued in 30-day durations or as determined by clinical review.
Medium impact
Ampyra® (dalfampridine) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Humana Medicare Advantage prior authorization policy for Ampyra (dalfampridine) for multiple sclerosis, effective January 1, 2020, with the most recent revision dated September 24, 2025. The policy requires prior authorization and establishes three approval criteria (MS diagnosis, ambulatory status, significant walking impairment) and two exclusions (seizure history and moderate-to-severe renal impairment). No substantive clinical changes from previous versions are documented in this revision.
Medium impact
Padcev (enfortumab vedotin-ejfv) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Padcev (enfortumab vedotin-ejfv) prior authorization policy effective April 22, 2026, affecting coverage for locally advanced/metastatic urothelial cancer and muscle-invasive bladder cancer across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The policy clarifies approval criteria for monotherapy, combination therapy with pembrolizumab, and cisplatin-ineligibility documentation requirements. Billing teams must verify patient eligibility against updated criteria before claim submission to avoid denials.
Low impact
Givlaari® (givosiran) (Revised)
Humana·Effective Aug 27, 2025
Humana revised its Givlaari (givosiran) prior authorization policy effective August 27, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains three prior authorization criteria: confirmed acute hepatic porphyria diagnosis with elevated PBG/ALA or genetic confirmation, documented symptoms consistent with acute hepatic porphyria, and administration by a healthcare professional. This is a routine policy revision with no substantive coverage changes identified.
Medium impact
Palforzia® (peanut allergen powder) (Revised)
Humana·Effective May 27, 2026
Humana updated its Palforzia (peanut allergen powder) prior authorization policy for Medicare Advantage members on May 27, 2026. The policy requires prior authorization for all Palforzia dosing levels (Initial Dose through Level 11 Maintenance) and mandates confirmation of peanut allergy diagnosis via clinical history plus positive peanut-specific IgE or skin prick test. Approval is granted for plan year duration or per clinical review.
Medium impact
Pemazyre (pemigatinib) (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage updated its Pemazyre (pemigatinib) prior authorization policy effective March 25, 2026. The policy clarifies coverage for two indications: (1) unresectable locally advanced or metastatic cholangiocarcinoma with FGFR2 fusion/rearrangement after prior treatment, and (2) relapsed or refractory myeloid/lymphoid neoplasms with FGFR1 rearrangement. Both require prior authorization with 6-month initial and renewal approval periods. Claims will be denied if members have experienced disease progression on Pemazyre.
Medium impact
Non-FDA Approved Medications (Revised)
Humana·Effective Jun 3, 2020
Humana revised its Non-FDA Approved Medications policy (effective June 3, 2020, revised March 19, 2026) for 8 state Medicaid programs. Non-FDA approved medications are excluded from formularies by default unless the Humana P&T Committee specifically reviews and approves them as safe and effective. Coverage is limited to plan year duration with annual renewal. The policy clarifies that unapproved drugs differ from generic drugs and emphasizes that only P&T Committee-approved non-FDA medications (such as 17-alpha-hydroxyprogesterone for preterm delivery prophylaxis) will be covered.
Medium impact
Contraceptive Medications (Revised)
Humana·Effective Feb 28, 2024
Humana revised its Contraceptive Medications prior authorization policy (effective February 28, 2024) for commercial plans. The policy clarifies that contraceptives require prior authorization when medically necessary for specific diagnoses (acne, amenorrhea, dysmenorrhea, endometriosis, PCOS, etc.) and establishes strict exclusion criteria including pregnancy, cancer history, cardiovascular disease, and smoking. Billing teams must ensure prior authorization is obtained before processing claims and verify member eligibility against the exclusion list.
Medium impact
Tukysa (tucatinib) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage has revised its Tukysa (tucatinib) prior authorization policy effective October 22, 2025. The policy covers two HER2-positive cancer indications: metastatic/advanced breast cancer (with prior anti-HER2 therapy) and RAS wild-type colorectal cancer (with prior multi-agent chemotherapy). Both require combination therapy with trastuzumab, and breast cancer requires capecitabine. Billing teams must ensure prior authorization is obtained before dispensing and verify member meets all clinical criteria.
Medium impact
Trodelvy (sacituzumab govitecan-hziy) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Trodelvy (sacituzumab govitecan-hziy) prior authorization policy effective November 26, 2025, covering Medicare and Medicaid (Florida, Kentucky, South Carolina). The policy maintains two distinct approval pathways: one for triple-negative breast cancer requiring ≥2 prior therapies (one metastatic), and one for HR-positive/HER2-negative breast cancer requiring endocrine therapy plus ≥2 additional systemic therapies in metastatic setting. Both pathways exclude members with prior disease progression on Trodelvy and require single-agent use.
Low impact
Scenesse® (afamelanotide) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Scenesse® (afamelanotide) prior authorization policy for Medicare and Medicaid-Florida on November 26, 2025. The policy maintains coverage for this rare drug treatment for erythropoietic protoporphyria (EPP) in adult patients who meet specific diagnostic and clinical criteria. Billing teams must ensure prior authorization is obtained before dispensing this subcutaneous implant, and providers must document confirmed EPP diagnosis plus history of phototoxic cutaneous reactions.
Medium impact
Retevmo (selpercatinib) (Revised)
Humana·Effective Jul 8, 2020
Humana Medicare Advantage updated its Retevmo (selpercatinib) prior authorization policy on February 25, 2026, with a review date of January 29, 2026. This is a pharmacy coverage policy requiring prior authorization for selpercatinib across four specific cancer indications: RET fusion-positive non-small cell lung cancer, RET-mutant medullary thyroid cancer, RET fusion-positive thyroid cancer (radioactive iodine-refractory), and RET fusion-positive solid tumors. All approvals are limited to 6-month initial and renewal periods, with disease progression on therapy as a key exclusion criterion.
Medium impact
Thalomid® (thalidomide) (Revised)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage updated its Thalomid (thalidomide) prior authorization policy effective February 25, 2026, maintaining coverage for three indications (ENL, Multiple Myeloma, Waldenstrom's Macroglobulinemia) with consistent 6-month approval durations. No coverage criteria changes were made, but billing teams must ensure all new and renewal Thalomid requests include prior authorization and verify patient S.T.E.P.S.® program enrollment before dispensing.
Medium impact
Tabrecta (capmatinib) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage updated its Tabrecta (capmatinib) prior authorization policy on November 26, 2025. The policy requires prior authorization for this MET exon 14 skipping inhibitor in metastatic NSCLC patients, with approval contingent on documented MET exon 14 skipping mutation and denial of further coverage upon disease progression. This is a routine policy maintenance update with no material changes to coverage criteria.
Medium impact
Jelmyto (mitomycin) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Jelmyto (mitomycin) pharmacy coverage policy effective November 26, 2025, for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy establishes prior authorization requirements for intra-pyelocalyceal mitomycin treatment of low-grade upper tract urothelial cancer (LG-UTUC), with specific approval criteria and exclusions. This is a routine policy revision with no apparent changes to coverage scope, but billing teams must ensure prior authorization is obtained before claims are submitted.
Medium impact
Fensolvi® (leuprolide acetate) subcutaneous syringe (Revised)
Humana·Effective Dec 18, 2024
This is a revision to Humana's Fensolvi (leuprolide acetate) prior authorization policy for Medicare Advantage plans, updated December 18, 2024. The policy confirms that Fensolvi requires prior authorization for pediatric patients 2+ years old with central precocious puberty, with approval granted for plan year durations for both initial and renewal requests. Billing teams must ensure all Fensolvi claims are submitted with prior authorization before processing.
Medium impact
Zepzelca (lurbinectedin) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Zepzelca (lurbinectedin) prior authorization policy effective December 17, 2025. The policy covers two treatment pathways for small cell lung cancer: (1) single-agent use for metastatic SCLC with prior platinum-based chemotherapy progression, and (2) combination therapy with atezolizumab for extensive-stage SCLC as maintenance after first-line induction therapy. This is a routine policy update affecting Medicaid plans in Florida, Kentucky, and South Carolina, plus Medicare Advantage.
Medium impact
Durysta® (bimatoprost implant) (Revised)
Humana·Effective Jun 1, 2026
Humana revised its Durysta (bimatoprost implant) prior authorization policy effective June 1, 2026, for Florida, Kentucky, and South Carolina Medicaid. The policy maintains strict approval criteria requiring open angle glaucoma/ocular hypertension diagnosis and no prior Durysta treatment on the affected eye, with three key clinical exclusions (corneal endothelial dystrophy, prior corneal transplant, absent/ruptured posterior lens capsule). Billing teams must ensure prior authorization is obtained before claims submission for these state Medicaid programs.
Medium impact
Bynfezia Pen™ (octreotide acetate) injection (Revised)
Humana·Effective Feb 28, 2024
Humana Medicare Advantage updated the prior authorization policy for Bynfezia Pen (octreotide acetate) injection effective February 28, 2024. The policy maintains prior authorization requirements across six indications (acromegaly, metastatic carcinoid tumors, VIPomas, chemotherapy/radiation-induced diarrhea, AIDS-related severe secretory diarrhea, and carcinoid crisis hypotension), with a key requirement that members must have had previous treatment or intolerance with generic subcutaneous octreotide before coverage. No fundamental changes to approval criteria were identified in this revision.
Medium impact
Dojolvi™ (triheptanoin) Oral Liquid (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Dojolvi™ (triheptanoin) Oral Liquid prior authorization policy effective January 28, 2026. The policy requires prior authorization for coverage, with two mandatory approval criteria: (1) confirmed diagnosis of long-chain fatty acid oxidation disorders (VLCAD, CPT2, TFP, or LCHAD deficiency), and (2) genetic/molecular testing confirmation. Initial and renewal approvals are granted for plan year durations.
Medium impact
Tecartus™ (brexucabtagene autoleucel) (Revised)
Humana·Effective Feb 19, 2026
Humana Medicare Advantage revised its prior authorization policy for Tecartus (brexucabtagene autoleucel) effective February 19, 2026. The policy maintains coverage for relapsed/refractory mantle cell lymphoma and acute lymphoblastic leukemia in adults ≥18 years, with a maximum of one dose per lifetime approved for 60 days. Key requirements include documented CD19 expression for ALL cases, mandatory use with lymphodepleting chemotherapy (unless contraindicated), and exclusion of primary CNS lymphoma cases. All requests must be directed to Humana's Corporate Transplant Department.
High impact
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) prior authorization policy effective December 17, 2025. The policy clarifies coverage for HER2-positive breast cancer across three treatment scenarios: neoadjuvant therapy for locally advanced/inflammatory/early-stage disease, adjuvant therapy for early-stage disease at high recurrence risk, and first-line metastatic disease treatment. A critical 52-week/18-cycle lifetime treatment limit applies to both neoadjuvant and adjuvant therapy combined. All requests require prior authorization before dispensing.
Medium impact
Isturisa® (osilodrostat) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage updated its Isturisa® (osilodrostat) prior authorization policy effective April 22, 2026, expanding coverage to include endogenous hypercortisolemia with Cushing's syndrome (in addition to Cushing's disease). Both indications now require prior authorization confirming patient age ≥18, appropriate diagnosis, and failure of or ineligibility for surgery. Approval duration covers initial and renewal plan years.

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Archive by year

2023 2024 2025 2026

Blincyto® (blinatumomab) (Revised)

Arikayce® (liposomal amikacin for inhalation) (Revised)

Apadaz® (benzhydrocodone and acetaminophen) (Revised)

Ampyra® (dalfampridine) (Revised)

Padcev (enfortumab vedotin-ejfv) (Revised)

Givlaari® (givosiran) (Revised)

Palforzia® (peanut allergen powder) (Revised)

Pemazyre (pemigatinib) (Revised)

Non-FDA Approved Medications (Revised)

Contraceptive Medications (Revised)

Tukysa (tucatinib) (Revised)

Trodelvy (sacituzumab govitecan-hziy) (Revised)

Scenesse® (afamelanotide) (Revised)

Retevmo (selpercatinib) (Revised)

Thalomid® (thalidomide) (Revised)

Tabrecta (capmatinib) (Revised)

Jelmyto (mitomycin) (Revised)

Fensolvi® (leuprolide acetate) subcutaneous syringe (Revised)

Zepzelca (lurbinectedin) (Revised)

Durysta® (bimatoprost implant) (Revised)

Bynfezia Pen™ (octreotide acetate) injection (Revised)

Dojolvi™ (triheptanoin) Oral Liquid (Revised)

Tecartus™ (brexucabtagene autoleucel) (Revised)

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) (Revised)

Isturisa® (osilodrostat) (Revised)