All Insurance Policy Changes (Page 167)

Continuing from page 166. 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
Pomalyst (pomalidomide) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Pomalyst (pomalidomide) prior authorization policy for Medicare Advantage members effective January 1, 2022, with a revision date of May 27, 2026. This pharmacy policy maintains strict prior authorization requirements for multiple myeloma and Kaposi sarcoma indications, with no substantive coverage criteria changes from the previous version. Billing teams should verify current policy compliance for all Pomalyst requests, as the policy requires documentation of prior therapy failures and disease progression before approval.
Medium impact
Panretin® (alitretinoin) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Panretin® (alitretinoin) prior authorization policy for Medicare Advantage effective January 1, 2022, with the most recent revision dated December 17, 2025. The policy maintains coverage for topical treatment of AIDS-related Kaposi's sarcoma cutaneous lesions only when systemic therapy is not required. Billing teams must ensure prior authorization is obtained before dispensing and verify member meets both eligibility criteria: confirmed AIDS-related Kaposi's sarcoma diagnosis and no requirement for systemic anti-KS therapy.
Medium impact
Otic Antibiotics (Revised)
Humana·Effective Feb 28, 2024
Humana revised its Otic Antibiotics step therapy policy (effective 2/28/2024) for commercial plans covering Cetraxal, Cipro HC, Ciprodex, and Otovel. The policy requires members to have documented trial, intolerance, or contraindication to TWO of three first-line otic antibiotics (ciprofloxacin ear drops, ofloxacin ear drops, or neomycin-polymyxin-HC otic solution) before approval of branded otic antibiotic combinations. This is a step therapy requirement that must be met for coverage.
Medium impact
Oral Acne Antibiotics (Revised)
Humana·Effective Apr 24, 2024
Humana revised its Oral Acne Antibiotics step therapy policy (effective April 24, 2024) to implement a two-criterion prior authorization requirement. Members must have prior treatment history with both a non-delayed release minocycline formulation AND a non-delayed release doxycycline formulation before coverage is approved for listed oral acne antibiotics. This is a step therapy policy affecting 18 covered medications.
Medium impact
Nurtec™ ODT (rimegepant) (Revised)
Humana·Effective Feb 28, 2024
This is a 1-day-old policy revision for Nurtec ODT (rimegepant) that establishes prior authorization requirements for both acute migraine treatment and migraine prevention in commercial plans. Billing teams must verify that members meet specific clinical criteria (previous treatment failure with triptans for acute use, or inadequate response to oral preventives for prevention use) before claims will be approved.
Medium impact
Nuedexta® (dextromethorphan and quinidine) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for Nuedexta (dextromethorphan/quinidine) for treating Pseudobulbar Affect (PBA). The policy requires prior authorization and confirms four approval criteria: diagnosed PBA from neurologic disease, characteristic behavioral episodes, age 18+, and provider attestation that QT prolongation risks are outweighed by treatment benefits. No significant changes from the original policy are documented—this appears to be a routine review/revision update.
Medium impact
Nourianz™ (istradefylline) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Nourianz (istradefylline) prior authorization policy for Medicare Advantage members with Parkinson's disease. The policy requires prior authorization confirming the member has documented "off" periods on carbidopa/levodopa and has failed or has contraindications to at least two adjunctive medication classes (dopamine agonists, MAO-B inhibitors, or COMT inhibitors) before Nourianz can be covered. This is a routine policy revision effective January 1, 2022, with the most recent update dated November 26, 2025.
Medium impact
Ninlaro® (ixazomib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Ninlaro® (ixazomib) prior authorization policy effective January 1, 2026. The policy maintains two approval pathways for relapsed/refractory multiple myeloma: second-line therapy requiring at least one prior therapy combined with lenalidomide/dexamethasone or cyclophosphamide/dexamethasone, and third-line+ therapy requiring at least two prior therapies combined with pomalidomide/dexamethasone. Both require prior authorization with 6-month approval duration. Members with disease progression on Ninlaro are excluded. The revision date of January 1, 2026 indicates recent updates to clinical criteria or evidence standards.
Medium impact
Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Mircera (methoxy polyethylene glycol-epoetin beta) prior authorization policy effective November 26, 2025, for Medicaid members in South Carolina and Virginia. The policy maintains existing coverage criteria for anemia of chronic kidney disease but clarifies prior authorization requirements, iron store documentation thresholds, and hemoglobin monitoring standards for both initial and renewal requests.
Medium impact
Livalo® (pitavastatin) (Revised)
Humana·Effective Jan 1, 2022
Humana has revised its Livalo® (pitavastatin) pharmacy coverage policy effective January 1, 2022, with the most recent revision dated February 25, 2026. This is a Step Therapy policy requiring members to have documented previous treatment, intolerance, or contraindication to BOTH Zypitamag and ezetimibe before Livalo coverage is approved. Billing teams must ensure prior authorization is obtained with evidence of failed or contraindicated prior therapies before processing claims.
High impact
Lifetime Dosing Limits (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has implemented lifetime dosing limit edits at point-of-sale for select FDA-limited medications. Claims exceeding FDA lifetime maximums will be stopped for clinical review. Providers can request exceptions by attesting medical necessity, which may be approved through end of plan year if clinically supported by compendia and provider rationale.
High impact
Kyprolis® (carfilzomib) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Kyprolis (carfilzomib) prior authorization policy effective January 1, 2022, with the most recent revision dated May 27, 2026. The policy covers multiple myeloma and Waldenstrom's macroglobulinemia treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required for all Kyprolis use, with specific clinical criteria for approval based on disease stage, prior therapy lines, and combination therapy regimens.
Medium impact
Kuvan® (sapropterin) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Kuvan (sapropterin) prior authorization policy effective January 1, 2022, with updates as of August 27, 2025. The policy requires prior authorization for all Kuvan brand formulations, generic sapropterin, Javygtor, and Zelvysia products. Brand-name requests now require documented evidence of prior treatment failure, contraindication, or intolerance to generic sapropterin. This is a maintenance revision clarifying existing coverage criteria for PKU treatment.
Low impact
Koselugo (selumetinib) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Koselugo (selumetinib) prior authorization policy for Medicare Advantage members with neurofibromatosis type 1 (NF1) and symptomatic, inoperable plexiform neurofibromas. The policy requires prior authorization for this drug when used as monotherapy and denies approval if the member has experienced disease progression on the medication. This is a routine policy revision dated March 25, 2026.
Medium impact
Intravenous Iron Products (Revised)
Humana·Effective Mar 25, 2026
Humana updated its Intravenous Iron Products prior authorization policy (effective March 25, 2026) for Medicaid in Kentucky, South Carolina, and Virginia, and Medicare plans. The policy requires prior authorization for four IV iron products (Feraheme, Injectafer, Monoferric, ferumoxytol) with mandatory step therapy: patients must have documented prior therapy failure, contraindication, or intolerance to Infed (iron dextran) and Venofer (iron sucrose) before approval, except Medicare Part B continuation requests within 365 days. This is a billing workflow change requiring enhanced documentation review before claims submission.
Medium impact
Ingrezza® & Ingrezza Sprinkle (valbenazine) (Revised)
Humana·Effective Aug 27, 2025
Humana updated its Ingrezza (valbenazine) prior authorization policy for Medicare Advantage members effective August 27, 2025. The revised policy maintains prior auth requirements for two indications: tardive dyskinesia (with mandatory prior treatment/contraindication/intolerance to Austedo) and chorea associated with Huntington's disease (with same Austedo requirement). Key clinical additions include Black Box Warning language for depression/suicidal ideation risk in Huntington's disease patients and expanded warnings/precautions documentation.
Medium impact
Inbrija® (inhaled levodopa) (Revised)
Humana·Effective Jan 1, 2022
Humana has revised its Inbrija® (inhaled levodopa) pharmacy coverage policy for Medicare Advantage plans, effective January 1, 2022, with the most recent revision dated January 28, 2026. The policy maintains prior authorization requirements for this medication, which is used to treat breakthrough 'off' episodes in Parkinson's disease patients already on carbidopa/levodopa therapy. Billing teams must verify all three coverage criteria are met before processing claims and ensure prior authorization is obtained before dispensing.
Medium impact
Inbrija® (inhaled levodopa) (Revised)
Humana·Effective Mar 27, 2024
Humana revised its Inbrija® (inhaled levodopa) prior authorization policy effective March 27, 2024. The policy maintains existing prior authorization requirements for commercial plans covering this medication for Parkinson's disease 'off' episodes. Billing teams must verify all four approval criteria are met before claims are submitted to avoid denials.
High impact
Iclusig® (ponatinib) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Iclusig® (ponatinib) prior authorization policy effective April 22, 2026. The policy maintains strict prior authorization requirements for three indications: chronic phase CML (requires failure on 2+ TKIs or T315I mutation), accelerated/blast phase CML (requires no other kinase inhibitors available or T315I mutation), and Ph+ ALL (requires no other kinase inhibitors, T315I mutation, or use with chemotherapy). All approvals exclude members with disease progression on Iclusig. Billing teams must ensure prior authorization is obtained before dispensing for any of these indications.
Medium impact
Growth Hormone (Revised)
Humana·Effective Aug 28, 2024
Humana revised its Growth Hormone pharmacy coverage policy effective August 28, 2024, updating clinical criteria for prior authorization across 15 growth hormone products. The policy maintains coverage for pediatric indications (GH deficiency, SGA, SHOX deficiency, chronic renal insufficiency, Prader-Willi, Turner's, and Noonan syndromes) and adds adult coverage criteria. Billing teams must verify prior authorization requirements are in place for all growth hormone claims and ensure documentation meets the updated clinical criteria.
Medium impact
Gocovri® (amantadine extended release) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Gocovri (amantadine extended-release) prior authorization policy effective January 1, 2022, with updates as of November 26, 2025. The policy requires prior authorization for two indications: levodopa-induced dyskinesia in Parkinson's disease (requiring failed trial of immediate-release amantadine) and Parkinson's disease 'off' episodes (requiring prior treatment with or contraindication to at least two specific medication classes). Billing teams must verify that all Gocovri prescriptions meet these criteria before processing claims.
Medium impact
Fetzima® (levomilnacipran) (Revised)
Humana·Effective Aug 27, 2025
Humana Medicare Advantage has revised its Fetzima (levomilnacipran) prior authorization policy effective August 27, 2025. The policy now requires documentation of prior therapy, intolerance, or contraindication to specific antidepressants (SNRIs, generic bupropion, or mirtazapine) before Fetzima can be approved for Major Depressive Disorder treatment. This is a step-therapy requirement that may delay patient access and requires prior authorization submission with documented evidence of failed or contraindicated prior treatments.
Medium impact
Exondys 51 (eteplirsen) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Exondys 51 (eteplirsen) prior authorization policy effective January 1, 2022, with the most recent revision dated December 17, 2025. This policy establishes strict prior authorization requirements for this rare disease therapy used to treat Duchenne Muscular Dystrophy (DMD), requiring confirmation of exon 51-amenable mutations, specialist prescription, baseline ambulatory function testing, and corticosteroid stability before initial approval. Renewal requires documented improvement or maintenance of ambulatory function compared to predicted disease progression.
Medium impact
Empliciti (elotuzumab) (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Empliciti (elotuzumab) prior authorization policy effective February 25, 2026, clarifying coverage criteria for multiple myeloma treatment across Medicare, Medicaid-Florida, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires prior authorization and specifies that coverage is limited to patients with disease progression after 1-3 prior lines of therapy (with lenalidomide/dexamethasone or bortezomib/dexamethasone combinations) or at least 2 prior therapies including lenalidomide and proteasome inhibitors (with pomalidomide/dexamethasone). Billing teams must ensure all Empliciti requests meet these updated clinical criteria before claim submission.
Medium impact
EMSAM® (selegiline transdermal system) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Medicare Advantage prior authorization policy for EMSAM® (selegiline transdermal system) for treating major depressive disorder. The policy requires prior authorization and mandates that patients have failed or been intolerant to generic SSRIs, SNRIs, bupropion, or mirtazapine before EMSAM® can be approved. The revision date of February 25, 2026 indicates recent updates to this existing policy.

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Archive by year

2023 2024 2025 2026

Pomalyst (pomalidomide) (Revised)

Panretin® (alitretinoin) (Revised)

Otic Antibiotics (Revised)

Oral Acne Antibiotics (Revised)

Nurtec™ ODT (rimegepant) (Revised)

Nuedexta® (dextromethorphan and quinidine) (Revised)

Nourianz™ (istradefylline) (Revised)

Ninlaro® (ixazomib) (Revised)

Mircera® (methoxy polyethylene glycol-epoetin beta) (Revised)

Livalo® (pitavastatin) (Revised)

Lifetime Dosing Limits (Revised)

Kyprolis® (carfilzomib) (Revised)

Kuvan® (sapropterin) (Revised)

Koselugo (selumetinib) (Revised)

Intravenous Iron Products (Revised)

Ingrezza® & Ingrezza Sprinkle (valbenazine) (Revised)

Inbrija® (inhaled levodopa) (Revised)

Inbrija® (inhaled levodopa) (Revised)

Iclusig® (ponatinib) (Revised)

Growth Hormone (Revised)

Gocovri® (amantadine extended release) (Revised)

Fetzima® (levomilnacipran) (Revised)

Exondys 51 (eteplirsen) (Revised)

Empliciti (elotuzumab) (Revised)

EMSAM® (selegiline transdermal system) (Revised)