All Insurance Policy Changes (Page 169)

Continuing from page 168. 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
Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Opdualag (nivolumab and relatlimab-rmbw) prior authorization policy effective March 25, 2026. The policy applies to Medicare, Medicaid (Florida, Kentucky, South Carolina) and requires prior authorization for this immune checkpoint inhibitor combination therapy in patients 12+ years old with unresectable or metastatic melanoma. Key exclusions include prior disease progression on anti-PD-1/PD-L1 combination therapy and concurrent use with BRAF/MEK inhibitors. Initial and renewal approvals are valid for 6 months or as determined through clinical review.
Medium impact
Soaanz® (torsemide) (Revised)
Humana·Effective Jan 28, 2026
Humana has revised its Soaanz® (torsemide) pharmacy coverage policy effective January 28, 2026. This is a step therapy policy for Medicare Advantage members requiring prior authorization. Members must have prior treatment with at least two of the following loop diuretics before Soaanz approval: furosemide, bumetanide, or torsemide. The policy applies to treatment of edema associated with heart failure or renal disease.
Medium impact
Ryplazim (plasminogen, human-tvmh) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its prior authorization policy for Ryplazim (plasminogen, human-tvmh) effective December 17, 2025, for Medicare and select state Medicaid programs (FL, KY, SC, VA). This is a rare disease therapy requiring prior authorization with four specific clinical criteria: hematologist prescription, confirmed Type 1 plasminogen deficiency diagnosis, baseline plasminogen activity ≤45%, and documented history of associated lesions/symptoms. Billing teams must ensure all four criteria are met before claims are submitted and prior authorization is obtained.
Medium impact
Recorlev® (levoketoconazole) Tablet (Revised)
Humana·Effective Jan 22, 2025
Humana Medicare Advantage has revised its prior authorization policy for Recorlev® (levoketoconazole) effective January 22, 2025. The policy requires prior authorization for this orphan drug used to treat Cushing's syndrome, with three mandatory approval criteria: confirmed Cushing's syndrome diagnosis, patient ineligibility for or failure of surgical intervention, and documented prior treatment failure or contraindication/intolerance to oral ketoconazole. Billing teams must ensure all Recorlev claims include prior authorization and supporting clinical documentation before submission to avoid denials.
High impact
Pemetrexed Products (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Pemetrexed Products prior authorization policy effective September 24, 2025, affecting coverage for pemetrexed-based chemotherapy across multiple pemetrexed formulations (Alimta, Pemfexy, Pemrydi RTU, Axtle) for malignant pleural mesothelioma and non-squamous non-small cell lung cancer. The policy maintains prior authorization requirements and renal function exclusions (CrCl < 45 ml/min) but clarifies approved treatment combinations and adds new first-line pembrolizumab-combination therapy criteria for NSCLC patients without EGFR/ALK mutations.
Medium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·Effective May 1, 2026
Humana Kentucky Medicaid revised its prior authorization policy for Carvykti (ciltacabtagene autoleucel) effective May 1, 2026. The policy establishes strict approval criteria requiring diagnosis of relapsed/refractory multiple myeloma with prior treatment including immunomodulatory agents, proteasome inhibitors, and anti-CD38 monoclonal antibodies. Coverage is limited to one lifetime dose approved for 60 days, with three key exclusions: active hepatitis B/C, prior allogeneic transplant, and prior CAR-T therapy. All requests must be routed to the Corporate Transplant Department.
Medium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·Effective Feb 19, 2026
Humana Medicare Advantage has revised its Carvykti (ciltacabtagene autoleucel) coverage policy effective February 19, 2026. This is a CAR-T cell immunotherapy for relapsed/refractory multiple myeloma requiring prior authorization. The policy mandates five specific clinical criteria be met before approval, with a maximum of one lifetime dose approved for a 60-day duration. All requests must be routed to Humana's Corporate Transplant Department.
Medium impact
Aduhelm® (aducanumab-avwa) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage has revised its Aduhelm (aducanumab-avwa) pharmacy coverage policy, effective November 26, 2025. The policy now requires that ALL Aduhelm requests—both initial and renewal—mandate enrollment in an FDA-approved randomized controlled trial or NIH-supported clinical trial as the sole approval criterion. This is a restrictive coverage policy that essentially limits Aduhelm access to trial participants only.
Medium impact
Vabysmo® (faricimab-svoa) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Vabysmo (faricimab-svoa) prior authorization policy effective March 25, 2026, covering three retinal indications across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The policy maintains step therapy requirements (bevacizumab contraindication/intolerance or failed prior therapy) for all three indications, with a critical exception: Florida Medicaid requests are exempt from the bevacizumab step therapy requirement (^Does not apply to Florida Medicaid requests). This is a revised policy that supersedes previous guidance.
Medium impact
Cibinqo® (abrocitinib) (Revised)
Humana·Effective Dec 17, 2025
Humana revised its Cibinqo (abrocitinib) prior authorization policy effective December 17, 2025. This is a JAK inhibitor for moderate-to-severe atopic dermatitis in patients 12+ years old. The policy requires prior authorization and mandates documented failure/contraindication/intolerance with both Dupixent AND Rinvoq before approval. Claims will be denied if these prerequisites are not met.
High impact
Tezspire™ (tezepelumab-ekko) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage has revised its Tezspire (tezepelumab-ekko) prior authorization policy effective November 26, 2025. The policy maintains coverage for severe asthma and chronic rhinosinusitis with nasal polyposis but requires strict prior authorization with specific clinical criteria, including documented exacerbations, maximum tolerated ICS/LABA therapy, and prohibition of concurrent use with other biologic agents (anti-IgE, anti-IL4, anti-IL5). Billing teams must verify prior authorization is obtained before dispensing and ensure claims meet all documented criteria.
Medium impact
Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)
Humana·Effective May 27, 2026
Humana revised its Pluvicto (lutetium Lu 177 vipivotide tetraxetan) pharmacy coverage policy effective May 27, 2026, for Medicare and four Medicaid state programs (Florida, Kentucky, South Carolina, Virginia). The policy maintains prior authorization requirements for this radioligand therapeutic agent used in metastatic castration-resistant prostate cancer, with specific criteria around PSMA-positive disease confirmation, prior ARPI therapy failure, and taxane chemotherapy status. Billing teams must ensure all Pluvicto requests comply with the four approval criteria and document the required clinical conditions to avoid claim denials.
Medium impact
Byooviz® (ranibizumab-nuna) (Revised)
Humana·Effective Feb 25, 2026
Humana updated its Byooviz (ranibizumab-nuna) prior authorization policy effective February 25, 2026, affecting Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy requires prior authorization for three ophthalmic conditions with a key exception: Florida Medicaid requests are exempt from bevacizumab step-therapy requirements, and Medicare Part B continuation therapy within 365 days bypasses step therapy.
Medium impact
Ztalmy® (ganaxolone) (Revised)
Humana·Effective Jul 27, 2022
Humana updated its Ztalmy® (ganaxolone) pharmacy coverage policy for Medicare Advantage members with a revision date of March 25, 2026. The policy establishes prior authorization requirements for Ztalmy oral suspension (50 mg/ml) for treating seizures associated with CDKL5 Deficiency Disorder in patients age 2 and older. The single approval criterion requires documentation of a confirmed CDKL5 Deficiency Disorder (CDD) diagnosis, with coverage approved for the full plan year on initial and renewal requests.
Medium impact
Vijoice® (alpelisib) (Revised)
Humana·Effective Jul 27, 2022
Humana Medicare Advantage has revised its Vijoice® (alpelisib) prior authorization policy effective February 25, 2026. The policy covers this PI3K inhibitor for adult and pediatric patients (age 2+) with severe manifestations of PIK3CA-Related Overgrowth Spectrum (PROS) requiring systemic therapy, contingent on meeting three clinical criteria: confirmed PIK3CA gene mutation, PROS diagnosis, and physician-documented severe/life-threatening disease manifestations. All three Vijoice formulations (50mg, 125mg, 250mg tablets and 50mg granule packets) require prior authorization before dispensing.
Low impact
Korsuva™ (difelikefalin) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage has revised its prior authorization policy for Korsuva™ (difelikefalin) effective May 27, 2026. The policy maintains existing coverage criteria requiring CKD-associated pruritus diagnosis and consistent hemodialysis (3+ times weekly for 3 months), with initial approval for 6 months and renewal approvals for plan year durations. This is a routine policy revision with no changes to approval criteria or billing requirements.
Medium impact
Enjaymo™ (sutimlimab-jome) (Revised)
Humana·Effective Jul 23, 2025
Humana Medicaid Ohio has updated its prior authorization policy for Enjaymo (sutimlimab-jome) effective July 23, 2025. This is a revised policy (originally effective July 27, 2022) with updated clinical criteria for initial approval and renewal. The billing team must ensure all Enjaymo claims for Ohio Medicaid members include prior authorization documentation demonstrating patient meets strict diagnostic, lab, vaccination, and medication interaction criteria before dispensing.
High impact
Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage is updating its prior authorization policy for abuse-deterrent oxycodone tablets (RoxyBond, Oxaydo, and generics), effective January 1, 2026. The policy requires prior authorization for all abuse-deterrent oxycodone oral tablets and mandates that patients have failed or been intolerant to at least two alternative immediate-release opioids before approval. This is a revision to the original July 27, 2022 policy.
Medium impact
Reyvow™ (lasmiditan) (Revised)
Humana·Effective Mar 27, 2024
Humana updated its Reyvow™ (lasmiditan) prior authorization policy on March 27, 2024. The policy requires prior authorization for acute migraine treatment and mandates documented previous treatment failure or contraindication to Nurtec or Ubrelvy before approval. Key safety restrictions include limiting use to no more than 4 migraines per 30-day period and requiring 8-hour driving/machinery restrictions post-dose.
Medium impact
Calcitonin gene-related peptide (CGRP) inhibitors (Revised)
Humana·Effective Mar 27, 2024
Humana revised its CGRP inhibitor prior authorization policy effective March 27, 2024. For migraine prevention with Ajovy and Emgality (120 mg/mL), the policy now requires prior treatment failure with Aimovig OR Nurtec ODT OR Qulipta (with a Medicaid-South Carolina exception). This expands the previous step-therapy requirements and clarifies which agents satisfy initial treatment failure criteria before approving second-line CGRP inhibitors.
Medium impact
Meloxicam oral suspension (Revised)
Humana·Effective Jul 24, 2024
Humana updated its meloxicam oral suspension prior authorization policy (revised July 24, 2024) for commercial plans. The policy requires prior authorization for meloxicam oral suspension across three indications: osteoarthritis, rheumatoid arthritis, and juvenile rheumatoid arthritis. Coverage requires documented prior therapy failure, contraindication, or intolerance with both meloxicam tablets AND ibuprofen oral suspension, plus exclusion screening for NSAID allergies and recent CABG surgery.
Low impact
Hyftor™ (sirolimus topical gel) (Revised)
Humana·Effective Sep 28, 2025
Humana updated its Hyftor™ (sirolimus topical gel) prior authorization policy effective September 28, 2022, with a recent revision dated September 24, 2025. This is a maintenance update to the existing policy requiring prior authorization for Hyftor use in Medicare Advantage members with tuberous sclerosis complex (TSC) who have ≥3 facial angiofibromas and are not on systemic mTOR inhibitors. No billing codes are specified in this policy document.
Medium impact
Zonisade™ (zonisamide) (Revised)
Humana·Effective Jun 24, 2026
Humana Medicare Advantage updated its Zonisade (zonisamide) oral suspension prior authorization policy effective June 24, 2026. The policy now requires prior authorization for this adjunctive seizure medication and mandates that members must have failed or be unable to use zonisamide capsules AND at least one other antiepileptic drug before approval. This is a revision to the original October 26, 2022 policy.
Medium impact
Nexiclon™ XR (clonidine ER) tablet (Revised)
Humana·Effective Oct 26, 2022
Humana updated its Nexiclon™ XR (clonidine ER) pharmacy coverage policy for Medicare Advantage members, effective October 26, 2022, with a revision dated September 24, 2025. This is a prior authorization (PA) policy requiring members to have a hypertension diagnosis AND prior treatment failure, intolerance, or contraindication to immediate-release clonidine before coverage is approved. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility against both criteria.
Medium impact
Camzyos™ (mavacamten) (Revised)
Humana·Effective Oct 26, 2025
Humana Medicare Advantage updated its prior authorization policy for Camzyos (mavacamten) on October 22, 2025. The policy establishes strict approval criteria requiring diagnosis confirmation, NYHA Class II-III symptoms, LVEF >55% at initiation, and prior treatment failure/intolerance to beta-blockers or non-dihydropyridine calcium channel blockers. Initial approval is for 6 months with renewal requiring LVEF >50%, clinical improvement documentation, and provider attestation against concurrent septal reduction therapy.

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Archive by year

2023 2024 2025 2026

Opdualag™ (nivolumab and relatlimab-rmbw) (Revised)

Soaanz® (torsemide) (Revised)

Ryplazim (plasminogen, human-tvmh) (Revised)

Recorlev® (levoketoconazole) Tablet (Revised)

Pemetrexed Products (Revised)

Carvykti™ (ciltacabtagene autoleucel) (Revised)

Carvykti™ (ciltacabtagene autoleucel) (Revised)

Aduhelm® (aducanumab-avwa) (Revised)

Vabysmo® (faricimab-svoa) (Revised)

Cibinqo® (abrocitinib) (Revised)

Tezspire™ (tezepelumab-ekko) (Revised)

Pluvicto (lutetium Lu 177 vipivotide tetraxetan) (Revised)

Byooviz® (ranibizumab-nuna) (Revised)

Ztalmy® (ganaxolone) (Revised)

Vijoice® (alpelisib) (Revised)

Korsuva™ (difelikefalin) (Revised)

Enjaymo™ (sutimlimab-jome) (Revised)

Abuse Deterrent Oxycodone tablets (RoxyBond,Oxaydo, generics)

Reyvow™ (lasmiditan) (Revised)

Calcitonin gene-related peptide (CGRP) inhibitors (Revised)

Meloxicam oral suspension (Revised)

Hyftor™ (sirolimus topical gel) (Revised)

Zonisade™ (zonisamide) (Revised)

Nexiclon™ XR (clonidine ER) tablet (Revised)

Camzyos™ (mavacamten) (Revised)