All Insurance Policy Changes (Page 168)

Continuing from page 167. 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
Dihydroergotamine Products (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Dihydroergotamine Products prior authorization policy (effective 1/1/2022, revised 9/24/2025). The policy requires prior authorization for dihydroergotamine nasal spray and injection for acute migraine treatment. Prior to approval, members must demonstrate previous treatment, intolerance, or contraindication to at least TWO of four specified first-line agents (naproxen, naratriptan, rizatriptan, or sumatriptan). Approvals are granted for the plan year duration with annual renewal options.
Medium impact
Desmopressin Nasal Spray (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage updated its Desmopressin Nasal Spray prior authorization policy (revision dated April 24, 2024). The policy requires prior authorization for desmopressin nasal spray with one key criterion: members must have had previous treatment or intolerance with generic desmopressin tablets. Approval is granted for the initial plan year duration. This is a refreshed policy document with the same effective date (January 1, 2022) but recent clinical review.
Medium impact
Defitelio® (defibrotide sodium) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its Defitelio (defibrotide sodium) pharmacy coverage policy effective January 1, 2022, with the most recent revision dated March 25, 2026. This is a prior authorization policy for treating veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) following hematopoietic stem-cell transplantation. The policy requires prior authorization for all uses and explicitly prohibits concomitant use with systemic anticoagulants or fibrinolytic therapy.
Medium impact
Dayvigo™ (lemborexant) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage has revised its Dayvigo (lemborexant) prior authorization policy, effective January 1, 2022, with the most recent revision dated December 17, 2025. The policy requires prior authorization for this insomnia medication and mandates that members have documented failed treatment, contraindication, or intolerance to Belsomra (suvorexant) or trazodone before approval. The policy explicitly excludes members with narcolepsy from coverage.
Medium impact
Darzalex® (daratumumab) (Revised)
Humana·Effective Jan 28, 2026
Humana revised its Darzalex (daratumumab) prior authorization policy effective January 28, 2026, for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy clarifies coverage criteria for newly diagnosed and relapsed/progressive multiple myeloma, specifying required combination therapies and prior treatment thresholds. No substantive clinical coverage changes are apparent—this is a policy refinement/republication.
High impact
Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Revised)
Humana·Effective Jan 1, 2022
This is a revised Darzalex Faspro (daratumumab and hyaluronidase-fihj) prior authorization policy effective January 1, 2022, with the most recent revision dated March 25, 2026. The policy covers three indications: multiple myeloma (newly diagnosed and relapsed/progressive disease), light chain amyloidosis (newly diagnosed), and high-risk smoldering multiple myeloma. All requests require prior authorization and must meet specific combination therapy or monotherapy criteria with documented clinical justification.
Medium impact
Bowel Prep Agents (Revised)
Humana·Effective May 22, 2024
Humana has revised its Bowel Prep Agents pharmacy coverage policy (effective January 1, 2022, revised May 22, 2024) to implement step therapy requiring members to have a documented trial, intolerance, or contraindication to Clenpiq before coverage of alternative bowel prep agents (MoviPrep, OsmoPrep, Plenvu, Sutab, Suprep, Suflave, and generic equivalents). This is a step therapy requirement that affects all bowel prep prescriptions for covered members.
Medium impact
Bosulif® (bosutinib) (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage updated its Bosulif (bosutinib) prior authorization policy effective January 1, 2022, with the most recent revision on April 22, 2026. This policy requires prior authorization for bosutinib coverage in Medicare Advantage members with Philadelphia chromosome-positive chronic myelogenous leukemia (CML), with specific approval criteria and exclusions based on disease phase, prior treatment, and specific mutations. The billing team must ensure all Bosulif claims include prior authorization documentation and verify member eligibility against the stated clinical criteria before claim submission.
Medium impact
Bosentan Products (Revised)
Humana·Effective Jan 1, 2022
This is a revised Humana Medicare Advantage prior authorization policy for bosentan products (Tracleer) used to treat pulmonary arterial hypertension (PAH). The policy requires prior authorization for all bosentan formulations and mandates that patients have confirmed PAH diagnosis via right heart catheterization. For brand Tracleer and generic bosentan oral suspension, prior treatment, intolerance, or contraindication with generic bosentan tablet must be documented. The policy emphasizes critical safety monitoring including liver function tests, hemoglobin levels, and monthly pregnancy testing due to black box warnings.
High impact
Bortezomib products (Velcade and Bortezomib for injection) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its prior authorization policy for bortezomib products (Velcade and generic bortezomib for injection) effective January 1, 2022, with the most recent revision dated February 25, 2026. The policy covers three indications: mantle cell lymphoma, multiple myeloma, and Waldenström's macroglobulinemia, all requiring prior authorization. A key exclusion applies across all three indications: members who have experienced disease progression while on a bortezomib-containing regimen may not receive approval. This is a recent update (1 day old) affecting Medicaid programs in Kentucky and South Carolina, plus Medicare.
Medium impact
BiDil® (isosorbide dinitrate/hydralazine) (Revised)
Humana·Effective Jan 1, 2022
Humana revised its BiDil® (isosorbide dinitrate/hydralazine) prior authorization policy effective January 1, 2022, with the most recent revision dated April 22, 2026. The policy requires prior authorization for BiDil tablet coverage in Medicare Advantage members with NYHA Class II-IV heart failure who have prior therapy with isosorbide dinitrate combined with hydralazine. Billing teams must ensure all BiDil claims include documented prior authorization and meet the two clinical criteria before submission.
Medium impact
Balversa (erdafitinib) (Revised)
Humana·Effective Feb 25, 2026
Humana revised its Medicare Advantage prior authorization policy for Balversa (erdafitinib) effective February 25, 2026. The policy maintains three strict approval criteria: locally advanced/metastatic urothelial carcinoma with documented FGFR3 genetic alterations, and use as subsequent therapy after at least one prior systemic therapy line including a PD-1/PD-L1 inhibitor. Initial and renewal approvals are limited to 6-month periods, and billing teams must verify genetic testing documentation is in the medical record before claim submission.
Medium impact
Austedo® & Austedo® XR (deutetrabenazine) (Revised)
Humana·Effective Jan 1, 2022
Humana updated its Medicare Advantage prior authorization policy for Austedo® & Austedo® XR (deutetrabenazine) on June 25, 2025. The policy maintains prior authorization requirements for tardive dyskinesia and chorea associated with Huntington's disease, with approval duration for both initial and renewal covering the plan year. Key clinical criteria remain unchanged, including documented failure of dopamine-blocking agent reduction for tardive dyskinesia and confirmed Huntington's disease diagnosis for chorea treatment.
High impact
Anticholinergic Polypharmacy Agents (Revised)
Humana·Effective May 13, 2026
Humana has updated its Anticholinergic Polypharmacy guidance (revised May 13, 2026) to implement a safety edit that restricts concurrent use of multiple anticholinergic medications for members aged 65+, unless the provider attests that benefits outweigh risks per American Geriatrics Society Beers Criteria and provides patient education. Members in hospice are exempt from this restriction. This affects pharmacy claims across Medicare and multiple state Medicaid programs.
Medium impact
Actinic Keratosis Agents (Revised)
Humana·Effective Jan 1, 2022
Humana Medicare Advantage revised its Actinic Keratosis Agents prior authorization policy (effective 1/1/2022, revised 11/26/2025). The policy covers diclofenac topical gel and Klisyri (tirbanibulin) ointment for actinic keratosis treatment, requiring prior authorization. Billing teams must ensure all claims for these agents include documentation that the member has tried, experienced intolerance to, or has contraindications to generic imiquimod 5% cream or topical fluorouracil before requesting approval.
Medium impact
Livtencity (maribavir) tablet (Revised)
Humana·Effective Jan 19, 2022
This is a revised Humana Medicare Advantage prior authorization policy for Livtencity (maribavir) effective January 19, 2022, with the most recent revision dated March 25, 2026. The policy requires prior authorization for this CMV treatment drug and specifies two strict approval criteria: patient must have post-transplant CMV infection AND be refractory to ganciclovir, valganciclovir, cidofovir, or foscarnet. Critical warnings include drug interaction risks with immunosuppressants (tacrolimus, cyclosporine, sirolimus, everolimus) requiring frequent monitoring.
Medium impact
Besremi (ropeginterferon alfa-2b-njft) (Revised)
Humana·Effective Nov 26, 2025
Humana updated its Besremi (ropeginterferon alfa-2b-njft) prior authorization policy for Medicare Advantage members with Polycythemia Vera, effective November 26, 2025. The policy requires prior authorization for all Besremi subcutaneous syringes and maintains six specific exclusion criteria (hepatic decompensation, severe psychiatric disorders, immunosuppressed transplant recipients, hypersensitivity, active autoimmune disease, and disease progression on therapy). No changes to billing codes or coverage criteria are noted compared to the original effective date; this is a routine policy revision.
Medium impact
Xipere® (triamcinolone acetonide) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Xipere (triamcinolone acetonide) prior authorization policy effective October 22, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy requires prior authorization for this suprachoroidal injectable suspension used to treat macular edema associated with uveitis. The single clinical criterion is confirmation of macular edema associated with uveitis diagnosis. Approval duration is determined by plan year or clinical review for both initial and renewal requests.
Medium impact
Voxzogo™ (vosoritide) (Revised)
Humana·Effective Feb 23, 2022
Humana Medicare Advantage updated its Voxzogo (vosoritide) prior authorization policy on June 24, 2026. The policy requires prior authorization for this CNP analog injection used to treat pediatric achondroplasia, with three specific approval criteria: genetically confirmed diagnosis, open epiphyses confirmed by imaging, and specialist prescribing/consultation. Approval is granted in plan year durations or through clinical review.
Medium impact
Tarpeyo™ (budesonide) delayed-release capsules (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage has revised its prior authorization policy for Tarpeyo (budesonide) delayed-release capsules for primary IgA nephropathy treatment, effective March 25, 2026. The policy requires two approval criteria: confirmed IgAN diagnosis by biopsy and use to reduce kidney function loss in patients at risk for disease progression. Billing teams must ensure all Tarpeyo claims include prior authorization before submission to avoid denials.
Medium impact
Fyarro (sirolimus protein-bound particles for injectable suspension) (Revised)
Humana·Effective Jun 24, 2026
Humana revised its prior authorization policy for Fyarro (sirolimus protein-bound particles for injectable suspension) effective June 24, 2026. The policy covers this mTOR inhibitor for adult patients with locally advanced unresectable or metastatic perivascular epithelioid cell tumor (PEComa) as monotherapy. Billing teams must ensure prior authorization is obtained before claim submission for Medicare and Medicaid members in Florida, Kentucky, and South Carolina.
Medium impact
Dartisla ODT (glycopyrrolate) (Revised)
Humana·Effective Oct 22, 2025
Humana has revised its Dartisla ODT (glycopyrrolate) coverage policy, effective October 22, 2025. This is a step therapy policy requiring members to have previous treatment or intolerance to glycopyrrolate tablet before Dartisla ODT (the orally disintegrating formulation) will be covered for adjunct peptic ulcer treatment. This is a pharmacy policy affecting prior authorization requirements for this specific medication.
Medium impact
Tavneos™ (avacopan) (Revised)
Humana·Effective Dec 17, 2025
Humana updated its Tavneos (avacopan) prior authorization policy for Medicare Advantage members on December 17, 2025. The policy maintains strict coverage criteria requiring diagnosis of GPA or MPA, positive ANCA testing, severe disease manifestations, specialist prescribing, and combination therapy. For renewals, members must demonstrate positive clinical response with disease stabilization or absence of progression.
Medium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (Revised)
Humana·Effective Aug 27, 2025
Humana revised its prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) effective August 27, 2025. The policy clarifies coverage criteria for generalized myasthenia gravis (gMG) and chronic inflammatory demyelinating polyneuropathy (CIDP), requiring prior authorization and specific clinical criteria including specialist oversight, documented diagnosis confirmation, and prior treatment history for Medicaid and Medicare Ohio members.
Medium impact
Kimmtrak (tebentafusp-tebn) (Revised)
Humana·Effective Oct 22, 2025
Humana revised its Kimmtrak (tebentafusp-tebn) prior authorization policy effective October 22, 2025, for Medicare and Medicaid (Kentucky and South Carolina). The policy requires prior authorization for this rare cancer immunotherapy targeting HLA-A*02:01-positive unresectable or metastatic uveal melanoma patients. Key criteria include HLA-A*02:01 genetic confirmation and monotherapy use; patients with prior disease progression on Kimmtrak are excluded from coverage.

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Archive by year

2023 2024 2025 2026

Dihydroergotamine Products (Revised)

Desmopressin Nasal Spray (Revised)

Defitelio® (defibrotide sodium) (Revised)

Dayvigo™ (lemborexant) (Revised)

Darzalex® (daratumumab) (Revised)

Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) (Revised)

Bowel Prep Agents (Revised)

Bosulif® (bosutinib) (Revised)

Bosentan Products (Revised)

Bortezomib products (Velcade and Bortezomib for injection) (Revised)

BiDil® (isosorbide dinitrate/hydralazine) (Revised)

Balversa (erdafitinib) (Revised)

Austedo® & Austedo® XR (deutetrabenazine) (Revised)

Anticholinergic Polypharmacy Agents (Revised)

Actinic Keratosis Agents (Revised)

Livtencity (maribavir) tablet (Revised)

Besremi (ropeginterferon alfa-2b-njft) (Revised)

Xipere® (triamcinolone acetonide) (Revised)

Voxzogo™ (vosoritide) (Revised)

Tarpeyo™ (budesonide) delayed-release capsules (Revised)

Fyarro (sirolimus protein-bound particles for injectable suspension) (Revised)

Dartisla ODT (glycopyrrolate) (Revised)

Tavneos™ (avacopan) (Revised)

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

Kimmtrak (tebentafusp-tebn) (Revised)