All Insurance Policy Changes (Page 173)

Continuing from page 172. 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
Orserdu (elacestrant) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage revised its Orserdu (elacestrant) prior authorization policy effective October 22, 2025. The policy requires prior authorization for this selective estrogen receptor degrader (SERD) used to treat ER-positive, HER2-negative, ESR1-mutated advanced/metastatic breast cancer in patients with disease progression after at least one prior endocrine therapy line. Coverage is approved for 6-month initial and renewal periods when all four clinical criteria are met.
Low impact
Tzield (teplizumab) intravenous solution (Revised)
Humana·Effective Apr 26, 2023
Humana Medicare Advantage has revised its prior authorization policy for Tzield (teplizumab) intravenous solution, a drug indicated to delay Stage 3 Type 1 diabetes onset in patients with Stage 2 Type 1 diabetes. The policy requires prior authorization for this drug based on confirmed Stage 2 T1D diagnosis (at least two positive pancreatic islet autoantibodies with dysglycemia). Approvals are granted in plan year durations or through clinical review, with no specific billing code changes mentioned.
Medium impact
Pradaxa® (dabigatran etexilate) oral pellet (Revised)
Humana·Effective Apr 26, 2023
This is a revised Humana Medicare Advantage prior authorization policy for Pradaxa® (dabigatran etexilate) oral pellet, a direct thrombin inhibitor for treating venous thromboembolism (VTE) in pediatric patients aged 3 months to less than 12 years. The policy requires prior authorization and mandates that members must have either acute VTE treatment with parenteral anticoagulant for ≥5 days OR prior VTE history, AND prior failure/contraindication/intolerance to specific alternative anticoagulants (Xarelto oral suspension, Eliquis apixaban sprinkle capsule, or Eliquis apixaban tablet suspension) before approval.
Medium impact
Jaypirca (pirtobrutinib) (Revised)
Humana·Effective Apr 26, 2023
Humana Medicare Advantage has updated its prior authorization policy for Jaypirca (pirtobrutinib) effective April 26, 2023, with a revision date of April 22, 2026. The policy covers two indications: relapsed/refractory mantle cell lymphoma (after ≥2 prior lines including BTK inhibitor) and CLL/SLL (after prior covalent BTK inhibitor), both requiring monotherapy use and prior authorization. The revision clarifies coverage criteria and approval duration aligned to plan year.
Medium impact
Functional Family Therapy - MEDICAID - LOUISIANA (New)
Humana·Effective Apr 30, 2023
Humana Healthy Horizons Louisiana Medicaid has issued a clinical coverage policy for Functional Family Therapy (FFT) and Functional Family Therapy-Child Welfare (FFT-CW) effective April 30, 2023. This is an annual review update (10/22/2024) with minor grammatical changes. The policy establishes medical necessity criteria, billing restrictions (FFT cannot be billed with PRTF services), allowable concurrent services (medication management, individual therapy, CPST, PSR, ILSB), and discharge criteria for Louisiana Medicaid members ages 10-18 (0-18 for FFT-CW) with externalizing behaviors.
Medium impact
Zynyz (retifanlimab-dlwr) (Revised)
Humana·Effective Aug 27, 2025
Humana updated its prior authorization policy for Zynyz (retifanlimab-dlwr) effective August 27, 2025, covering two cancer indications: Merkel cell carcinoma and anal squamous cell carcinoma. The policy now specifies approval duration of 6 months for initial and renewal periods, establishes clear eligibility criteria including monotherapy use for MCC and combination or sequential therapy options for anal carcinoma, and includes a critical exclusion for patients with prior anti-PD-1/PD-L1 therapy progression. Billing teams must implement prior authorization requirements before requesting claims for this specialty oncology drug.
Medium impact
Syfovre® (pegcetacoplan) intravitreal solution (Revised)
Humana·Effective Dec 17, 2025
Humana has revised its Syfovre (pegcetacoplan) intravitreal solution coverage policy effective December 17, 2025. This is a prior authorization requirement policy for the treatment of geographic atrophy secondary to age-related macular degeneration. The policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. Prior authorization is required; coverage is contingent on GA diagnosis secondary to AMD and prescription by or in consultation with an ophthalmologist or retinal specialist.
Medium impact
Igalmi™ (dexmedetomidine) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicare Advantage has updated its prior authorization policy for Igalmi™ (dexmedetomidine) sublingual film, effective January 28, 2026. This is a pharmacy coverage policy requiring prior authorization for acute treatment of agitation associated with schizophrenia or bipolar I or II disorder in Medicare Advantage members. The policy mandates approval based on two criteria: confirmed diagnosis of schizophrenia or bipolar I/II disorder AND current agitation associated with these conditions.
Medium impact
Daybue™ (trofinetide) (Revised)
Humana·Effective Feb 25, 2026
Humana updated its Daybue (trofinetide) pharmacy coverage policy for Medicare Advantage members with Rett Syndrome, effective February 25, 2026. The policy requires prior authorization and confirms four mandatory approval criteria: confirmed Rett Syndrome diagnosis, prescription by a Rett Syndrome-experienced provider (neurologist/pediatric neurologist), laxative discontinuation before treatment, and completed kidney function tests (eGFR ≥30 mL/min/1.73m²). Billing teams must ensure all four criteria are verified before claims processing to prevent denials.
Medium impact
Cuvrior™ (trientine tetrahydrochloride) (Revised)
Humana·Effective May 24, 2023
This is a revision to Humana's Cuvrior (trientine tetrahydrochloride) prior authorization policy for Medicare Advantage members with Wilson's disease. The policy requires prior authorization and confirms three mandatory clinical criteria: confirmed Wilson's disease diagnosis, completion of initial copper removal therapy, and demonstrated tolerance to penicillamine. The revision date of December 17, 2025 indicates recent updates to this rare disease medication coverage.
Medium impact
Hemgenix (etranacogene dezaparvovec-drlb) (Revised)
Humana·Effective Jun 1, 2023
Humana updated its Hemgenix (etranacogene dezaparvovec-drlb) prior authorization policy effective June 1, 2023, with a revision date of April 22, 2026. This gene therapy for Hemophilia B now requires prior authorization with five specific approval criteria: patient age ≥18 years, diagnosed Hemophilia B with prior Factor IX prophylaxis or serious bleeding history, no Factor IX inhibitors present, no significant liver dysfunction, and no previous gene therapy. The policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina with 60-day initial and renewal approval durations.
Medium impact
Skyclarys™ (omaveloxolone) (Revised)
Humana·Effective Mar 25, 2026
Humana Medicare Advantage updated its Skyclarys (omaveloxolone) prior authorization policy for Friedreich's ataxia treatment, effective March 25, 2026. The policy requires prior authorization with six specific approval criteria including genetic testing confirmation, specialist prescribing, and baseline laboratory tests (liver function, BNP, lipid panel) with mandatory monthly monitoring for the first three months.
Medium impact
Qalsody™ (tofersen) (Revised)
Humana·Effective Mar 25, 2026
Humana revised its Qalsody (tofersen) prior authorization policy effective March 25, 2026, for Medicaid members in Kentucky and South Carolina with SOD1-ALS. The policy establishes six initial approval criteria (including SOD1 mutation confirmation, elevated baseline neurofilament levels, functional ADL status, and riluzole co-therapy) and three renewal criteria focused on neurofilament reduction and maintained functional independence. Billing teams must implement prior authorization requirements before administering this intrathecal medication.
Medium impact
Veozah® (fezolinetant) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage has revised its prior authorization policy for Veozah® (fezolinetant) effective April 22, 2026. The policy requires prior authorization for this neurokinin 3 receptor antagonist used to treat moderate to severe vasomotor symptoms in menopausal patients. Coverage requires documented diagnosis of moderate to severe vasomotor symptoms AND prior treatment failure, contraindication, or intolerance to hormone therapy or SSRI/SNRI medications. Billing teams must implement prior authorization requirements and educate providers on the two mandatory approval criteria.
High impact
Lumryz (sodium oxybate) (Revised)
Humana·Effective Jul 26, 2023
Humana Medicare Advantage updated its Lumryz (sodium oxybate) prior authorization policy effective July 26, 2023, with a revision dated July 24, 2024. The policy maintains two distinct approval pathways: (1) Narcolepsy with cataplexy requires diagnosis confirmation and exclusivity of competing narcolepsy agents, with 3-month initial and 6-month renewal approvals; (2) Narcolepsy with excessive daytime sleepiness requires documented sleep testing and prerequisite trial/intolerance of CNS stimulants and modafinil before approval. The billing team must ensure all Lumryz requests include proper prior authorization before claim submission, as this is a controlled substance requiring enrollment in the Lumryz REMS Program.
High impact
Lumryz (sodium oxybate) (Revised)
Humana·Effective Jul 26, 2023
Humana updated its Lumryz (sodium oxybate) prior authorization policy effective July 26, 2023, with a revision dated July 24, 2024. The policy establishes two separate approval pathways: one for narcolepsy with cataplexy (requires prior Wakix failure/intolerance) and one for narcolepsy with excessive daytime sleepiness (requires documented sleep testing and prior CNS stimulant/Wakix failure). Both require initial 3-month and 6-month renewal approvals with documented clinical response. The policy mandates exclusive use—members cannot use Lumryz concurrently with Xyrem, Xywav, Wakix, or Sunosi.
Medium impact
Rezzayo Intravenous Solution (Revised)
Humana·Effective Aug 23, 2023
Humana Medicare Advantage has updated its prior authorization policy for Rezzayo (rezafungin) intravenous solution, effective August 23, 2023, with the most recent revision dated March 25, 2026. The policy requires prior authorization for candidemia and invasive candidiasis treatment, with approval limited to patients who have failed, have contraindications to, or are intolerant of caspofungin or micafungin. Both initial and renewal approvals are limited to 6-month periods.
High impact
Leqembi® (lecanemab-irmb) (Revised)
Humana·Effective Oct 22, 2025
Humana has revised its Leqembi (lecanemab) prior authorization policy for Kentucky and South Carolina Medicaid members, effective October 22, 2025. The policy now requires comprehensive documentation including cognitive assessments (MMSE/MoCA scores), amyloid-beta pathology confirmation via PET scan/CSF/blood biomarkers, recent brain MRI with specific exclusion criteria, ApoE ε4 status assessment, and exclusion of alternative diagnoses. Prior authorization is required for all initial and renewal requests with strict renewal criteria including continued cognitive monitoring and scheduled MRIs before the 5th, 7th, and 14th infusion doses.
Medium impact
LAMZEDE® (velmanase alfa-tycv) (Revised)
Humana·Effective Aug 23, 2023
Humana has revised its LAMZEDE® (velmanase alfa-tycv) pharmacy coverage policy effective August 23, 2023, with most recent updates as of April 22, 2026. This is a Prior Authorization policy covering LAMZEDE for non-central nervous system manifestations of alpha-mannosidosis in Medicare and Medicaid (Kentucky and South Carolina) members. Billing teams must ensure all LAMZEDE claims require prior authorization approval before processing.
Medium impact
Inpefa™ (sotagliflozin) (Revised)
Humana·Effective Aug 23, 2023
Humana has updated its Inpefa (sotagliflozin) pharmacy coverage policy for Medicare Advantage members, effective August 23, 2023 with a revision date of April 22, 2026. This is a Prior Authorization policy requiring members to meet specific clinical criteria: diagnosis of heart failure OR type 2 diabetes with chronic kidney disease and cardiovascular risk factors, PLUS prior treatment/intolerance/contraindication to Jardiance or Farxiga. Billing teams must ensure prior authorization is obtained before dispensing Inpefa tablets to avoid claim denials.
Medium impact
FILSPARI® (sparsentan) (Revised)
Humana·Effective Aug 23, 2023
Humana has updated its prior authorization policy for FILSPARI® (sparsentan) effective August 23, 2023, with a recent revision on October 22, 2025. This is a pharmacy coverage policy for Medicare Advantage members with primary immunoglobulin A nephropathy (IgAN) requiring prior authorization before dispensing. Key requirements include confirmation of IgAN diagnosis by biopsy, failure or intolerance of ACEi/ARB therapy, minimum eGFR ≥30 mL/min/1.73 m², discontinuation of conflicting medications (RAS inhibitors, endothelin receptor antagonists, aliskiren), mandatory liver function monitoring every 3 months, and pregnancy testing/contraception protocols.
Medium impact
Epkinly™ (epcoritamab-bysp) (Revised)
Humana·Effective Aug 23, 2023
Humana revised its prior authorization policy for Epkinly (epcoritamab-bysp), a bispecific antibody for relapsed/refractory lymphomas. The policy clarifies coverage criteria for DLBCL/high-grade B-cell lymphoma (requires 2+ prior therapy lines as monotherapy, excludes CNS involvement) and follicular lymphoma (allows monotherapy with 2+ prior lines OR combination therapy with lenalidomide/rituximab after 1+ prior line). All approvals are for 6-month periods with clinical review. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility against these specific clinical criteria.
High impact
Roctavian™ (valoctocogene roxaparvovec-rvox) (Revised)
Humana·Effective Feb 1, 2026
CRITICAL: Roctavian (valoctocogene roxaparvovec-rvox), a gene therapy for severe hemophilia A, was voluntarily withdrawn from the market in February 2026 for commercial reasons. This policy revision (April 22, 2026) reflects this market withdrawal. New treatment initiation is NO LONGER AVAILABLE, though previously treated patients will continue long-term follow-up. Billing teams must immediately STOP processing new prior authorization requests and deny any new treatment claims.
Medium impact
Adstiladrin (nadofaragene firadenovec-vncg) (Revised)
Humana·Effective Sep 4, 2023
Humana has updated its prior authorization policy for Adstiladrin (nadofaragene firadenovec-vncg), a gene therapy for high-risk BCG-unresponsive non-muscle invasive bladder cancer. The policy, revised June 24, 2026, applies to Medicare and Medicaid members in Florida and South Carolina. Billing teams must implement prior authorization requirements with specific clinical criteria before claims can be approved.
Medium impact
Vyjuvek™ (beremagene geperpavec-svdt) (Revised)
Humana·Effective Sep 27, 2023
Humana updated its Vyjuvek (beremagene geperpavec-svdt) prior authorization policy effective September 27, 2023, with a revision date of September 24, 2025. This is a gene therapy for dystrophic epidermolysis bullosa (DEB) requiring prior authorization across Medicare, Kentucky Medicaid, and South Carolina Medicaid. The policy establishes six mandatory approval criteria including patient age (≥6 months), confirmed COL7A1 genetic mutation, dermatologist prescription, no history of squamous cell carcinoma in treatment area, concurrent wound support care, and supporting documentation.

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Insurance Policy Changes Tracker: All Payer Updates (Page 173) | PolicyChanges.app

Orserdu (elacestrant) (Revised)

Tzield (teplizumab) intravenous solution (Revised)

Pradaxa® (dabigatran etexilate) oral pellet (Revised)

Jaypirca (pirtobrutinib) (Revised)

Functional Family Therapy - MEDICAID - LOUISIANA (New)

Zynyz (retifanlimab-dlwr) (Revised)

Syfovre® (pegcetacoplan) intravitreal solution (Revised)

Igalmi™ (dexmedetomidine) (Revised)

Daybue™ (trofinetide) (Revised)

Cuvrior™ (trientine tetrahydrochloride) (Revised)

Hemgenix (etranacogene dezaparvovec-drlb) (Revised)

Skyclarys™ (omaveloxolone) (Revised)

Qalsody™ (tofersen) (Revised)

Veozah® (fezolinetant) (Revised)

Lumryz (sodium oxybate) (Revised)

Lumryz (sodium oxybate) (Revised)

Rezzayo Intravenous Solution (Revised)

Leqembi® (lecanemab-irmb) (Revised)

LAMZEDE® (velmanase alfa-tycv) (Revised)

Inpefa™ (sotagliflozin) (Revised)

FILSPARI® (sparsentan) (Revised)

Epkinly™ (epcoritamab-bysp) (Revised)

Roctavian™ (valoctocogene roxaparvovec-rvox) (Revised)

Adstiladrin (nadofaragene firadenovec-vncg) (Revised)

Vyjuvek™ (beremagene geperpavec-svdt) (Revised)