All Insurance Policy Changes (Page 70)

Continuing from page 69. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Zepbound® (tirzepatide) (Revised)
Humana·Effective Jan 20, 2025
Humana Medicare Advantage now covers Zepbound (tirzepatide) for moderate to severe obstructive sleep apnea (OSA) in obese adults as of January 20, 2025. This is a NEW indication requiring prior authorization with specific clinical criteria including BMI ≥30, AHI/REI ≥15, and documented lifestyle modifications. Patients with type 1 or type 2 diabetes are excluded from coverage under this indication.
Medium impact
Zilxi® (minocycline) Topical Foam (Revised)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage has revised its prior authorization policy for Zilxi (minocycline) topical foam for rosacea treatment. The policy requires prior authorization and mandates that members must have documented previous treatment, intolerance, or contraindication with both topical metronidazole AND non-delayed release oral doxycycline before Zilxi can be approved. This is a recent policy (3 weeks old) that supersedes any older guidance on this drug.
Medium impact
Qbrexza® (glycopyrronium) Cloth (Revised)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage has implemented a prior authorization policy for Qbrexza® (glycopyrronium) cloth for primary axillary hyperhidrosis. Billing teams must obtain prior authorization before dispensing this medication. Coverage requires patients to meet three criteria: diagnosis of primary axillary hyperhidrosis for at least 6 months, HDSS rating of 3 or 4, and documented failure or intolerance to conventional treatments.
Medium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·Effective Oct 1, 2025
Humana Medicaid (Indiana) has established a new prior authorization policy for Vyloy (zolbetuximab-clzb), a monoclonal antibody for treating HER2-negative, CLDN18.2-positive gastric and gastroesophageal junction adenocarcinoma. Billing teams must now obtain prior authorization before claims are submitted for this IV therapy when used as first-line combination chemotherapy. Approval is granted for initial and renewal periods of 6 months or as determined by clinical review.
Medium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·Effective Oct 1, 2025
Humana Louisiana Medicaid is establishing a new prior authorization requirement for Vyloy (zolbetuximab-clzb), a cancer immunotherapy drug used to treat HER2-negative gastric and gastroesophageal junction adenocarcinoma. Coverage requires documented CLDN18.2 positivity and use as first-line therapy in combination with fluoropyrimidine and platinum chemotherapy. Prior authorization must be obtained before dispensing; initial and renewal approvals are valid for 6 months.
Medium impact
Vyloy (zolbetuximab-clzb) (New)
Humana·Effective Oct 1, 2025
Humana Medicaid (Ohio) has implemented a new prior authorization requirement for Vyloy (zolbetuximab-clzb), a monoclonal antibody for treating HER2-negative, CLDN18.2-positive gastric and gastroesophageal junction adenocarcinoma. The drug requires prior authorization when used as first-line therapy in combination with fluoropyrimidine and platinum chemotherapy, with initial and renewal approvals valid for 6 months.
Medium impact
Ruconest (C1 esterase inhibitor, recombinant) (New)
Humana·Effective Oct 1, 2025
Humana Indiana Medicaid has established a new Prior Authorization policy for Ruconest (C1 esterase inhibitor, recombinant) effective October 1, 2025. All claims for Ruconest must now meet 7 specific clinical criteria including HAE diagnosis confirmation, required laboratory documentation (C4, C1INH levels, C1q level), specialist treatment requirement, and documented recurrent angioedema history. This is a new coverage policy requiring immediate prior authorization submission before dispensing.
Medium impact
Talvey (talquetamab) (Revised)
Humana·Effective Nov 1, 2025
This is a revised prior authorization policy for Talvey (talquetamab) for Indiana Medicaid covering relapsed/refractory multiple myeloma. The policy requires prior authorization and specifies strict criteria: patients must have multiple myeloma diagnosis, relapsed/refractory disease, at least four prior lines of therapy (including anti-CD38 monoclonal antibody, proteasome inhibitor, and immunomodulatory agent), and Talvey must be used as a single agent. Claims will be denied if the patient has experienced disease progression while on Talvey.
Medium impact
Talvey (talquetamab) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Humana Medicaid (Ohio) prior authorization policy for Talvey (talquetamab), a bispecific T-cell engager for relapsed/refractory multiple myeloma. The policy requires members to have received at least four prior lines of therapy (including specific drug classes) and be using Talvey as a single agent. Prior authorization is required before coverage, with denials if disease progression occurs on therapy or if experimental/investigational use criteria are not met.
Medium impact
Zoryve (roflumilast) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its Zoryve (roflumilast) prior authorization policy effective January 1, 2026, with updates as of July 22, 2026. This pharmacy coverage policy establishes prior authorization requirements for Zoryve topical cream and foam across three indications: plaque psoriasis, atopic dermatitis, and seborrheic dermatitis. The policy requires specific diagnostic criteria and documentation of previous treatment failures or contraindications with established therapies before Zoryve can be approved.
Medium impact
Tyenne (tocilizumab) subcutaneous (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Tyenne (tocilizumab) subcutaneous, effective January 1, 2026, with updates as of July 22, 2026. The policy establishes specific clinical criteria for coverage across four indications: moderately to severely active rheumatoid arthritis (requires 2 prior failed/contraindicated therapies from a defined list), systemic juvenile idiopathic arthritis (age 2+), polyarticular juvenile idiopathic arthritis (age 2+, requires 2 prior failed/contraindicated therapies), and giant cell arteritis (age 18+, requires prior Rinvoq therapy failure/contraindication). All requests require prior authorization before dispensing.
Medium impact
Tyenne (tocilizumab) subcutaneous (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for Tyenne (tocilizumab) subcutaneous covering four indications: moderately to severely active rheumatoid arthritis (requires age ≥18 and prior therapy/contraindication/intolerance with two of three agents), systemic juvenile idiopathic arthritis (age ≥2), polyarticular juvenile idiopathic arthritis (age ≥2, with prior therapy requirement), and giant cell arteritis (age ≥18, with Rinvoq prior therapy requirement). The policy includes boxed warnings regarding serious infections, TB testing, GI perforation risk, and lab monitoring requirements.
Medium impact
Talvey (talquetamab) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicaid Louisiana policy for Talvey (talquetamab) establishing prior authorization requirements for relapsed/refractory multiple myeloma patients who have received at least four prior lines of therapy including specific drug classes. The policy was revised on July 22, 2026 (2 weeks old) and requires single-agent use only, with approval contingent on meeting all four clinical criteria and excluding patients with disease progression on Talvey.
Medium impact
Sutent (sunitinib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Sutent (sunitinib) prior authorization policy effective January 1, 2026, with updates finalized July 22, 2026. This pharmacy coverage policy establishes specific clinical criteria and exclusions for sunitinib approval across seven cancer indications (RCC adjuvant, thymomas/thymic carcinoma, GIST, advanced RCC, PNET, advanced thyroid carcinoma, and angiosarcoma). Key requirement: brand Sutent requests mandate documented intolerance or contraindication to generic sunitinib, and members with prior disease progression on sunitinib are excluded from coverage.
High impact
Simponi (golimumab) (Revised)
Humana·Effective Jan 1, 2026
Humana has revised its Simponi (golimumab) pharmacy coverage policy for Medicare Advantage members, effective January 1, 2026, with a July 22, 2026 revision. The policy establishes prior authorization requirements for Simponi across four indications (Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Ulcerative Colitis) with updated criteria requiring prior failure/contraindication/intolerance to specific biologic therapies before approval.
Medium impact
Rinvoq (upadacitinib) LQ Oral Solution (Revised)
Humana·Effective Jan 1, 2026
Humana has issued a revised prior authorization policy for Rinvoq (upadacitinib) LQ Oral Solution effective January 1, 2026, with updates as of July 22, 2026. Coverage is limited to two indications: psoriatic arthritis and polyarticular juvenile idiopathic arthritis in patients age 2+ with prior TNF blocker failure, contraindication, or intolerance. Prior authorization is required for all Rinvoq LQ oral solution prescriptions under this policy.
High impact
Rinvoq (upadacitinib) Extended Release Tablet (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage updated its Rinvoq (upadacitinib) prior authorization policy, effective January 1, 2026, with a revision date of July 22, 2026. The policy establishes specific clinical criteria for coverage across 9 indications including rheumatoid arthritis, psoriatic arthritis, atopic dermatitis, ulcerative colitis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, Crohn's disease, polyarticular juvenile idiopathic arthritis, and giant cell arteritis. All claims for Rinvoq must meet diagnosis, age, and prior therapy requirements before authorization.
Low impact
Wound Care - MEDICAID - LOUISIANA (Revised)
Humana·Effective Jul 20, 2026
This is a routine annual review of Louisiana Medicaid's wound care policy with NO coverage changes. The policy reaffirms that wound care supplies require prior authorization (3-month periods with documented medical necessity), wound care systems (thermal or sealed suction) are covered for specific indications (Stage III/IV chronic wounds, post-surgical dehiscence, non-adhering grafts), and portable hyperbaric oxygen chambers remain non-covered. Billing teams should ensure they continue applying these existing requirements without workflow modifications.
Medium impact
Yulithira (everolimus) (New)
Humana·Effective Jul 22, 2026
Humana has implemented a new prior authorization policy for Yulithira (everolimus) effective July 22, 2026, covering five oncologic and non-oncologic indications. All requests require documentation of intolerance or contraindication to generic everolimus AND meeting specific clinical criteria. Members with prior disease progression on everolimus are excluded from coverage across all indications.
Medium impact
Uterine Fibroid Surgical Treatments - MEDICAID - KENTUCKY (Revised)
Humana·Effective Jul 22, 2026
Humana Kentucky Medicaid will NOT cover cryoablation procedures for uterine fibroids (CPT 58578, 58999), effective 07/22/2026. The policy states there is insufficient medical evidence to support this as standard treatment. Prior authorization is required, but will be denied. This represents a non-coverage determination for a specific surgical intervention.
Medium impact
Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - VIRGINIA (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Virginia establishes new coverage for TPMT enzyme activity testing (CPT 84433) effective 07/22/2026. The test is covered for two indications: guiding thiopurine medication dosing prior to therapy initiation, or evaluating severe toxicity from thiopurine drugs. Members under 21 require medical necessity review per EPSDT requirements. This is a new policy with no prior guidance superseded.
Medium impact
Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - INDIANA (New)
Humana·Effective Jul 22, 2026
Humana Indiana Medicaid now covers TPMT enzyme activity testing (CPT 84433) for two specific indications: to guide medication dosing before initiating thiopurine therapy (azathioprine, mercaptopurine, thioguanine) or to assess severe toxicity from existing thiopurine therapy. This is a new policy effective July 22, 2026, with special EPSDT review requirements for members under age 21.
High impact
Spinal Fusion and Stabilization Surgery - MEDICAID - OHIO (New)
Humana·Effective Jul 22, 2026
Humana Healthy Horizons Ohio Medicaid has established a new clinical coverage policy for spinal fusion and stabilization surgery effective July 22, 2026. The policy outlines medical necessity criteria, prior authorization requirements, and coverage guidelines for procedures including artificial intervertebral disc replacement, corpectomy, facet joint replacement, and sacroiliac joint fusion. Billing teams must verify prior authorization requirements through the Ohio Medicaid Prior Authorization and Notification List and ensure all supporting documentation is submitted with authorization requests.
High impact
Spinal Decompression Surgery - MEDICAID - VIRGINIA (New)
Humana·Effective Jul 22, 2026
Humana Medicaid Virginia has released a new comprehensive spinal decompression surgery policy (effective 07/22/2026) establishing specific coverage criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy requires documented medical necessity including diagnostic imaging confirmation, failed conservative treatment (6 weeks minimum), and specific clinical/neurological findings. Billing teams must verify all authorization requirements before submitting claims for these procedures.
High impact
Spinal Decompression Surgery - MEDICAID - SOUTH CAROLINA (Revised)
Humana·Effective Jul 22, 2026
Humana revised its South Carolina Medicaid spinal decompression surgery coverage policy effective July 22, 2026, establishing specific medical necessity criteria for discectomy, laminectomy, foraminectomy, and related procedures. The policy defines coverage requirements based on diagnosis (herniated disc, myelopathy, fractures, infections, tumors), requires documented conservative treatment failure (6 weeks minimum), and specifies clinical and objective findings needed for approval. Billing teams must ensure prior authorization requests include diagnostic imaging confirmation and evidence of conservative treatment attempts before surgery.

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Archive by year

2023 2024 2025 2026

Zepbound® (tirzepatide) (Revised)

Zilxi® (minocycline) Topical Foam (Revised)

Qbrexza® (glycopyrronium) Cloth (Revised)

Vyloy (zolbetuximab-clzb) (New)

Vyloy (zolbetuximab-clzb) (New)

Vyloy (zolbetuximab-clzb) (New)

Ruconest (C1 esterase inhibitor, recombinant) (New)

Talvey (talquetamab) (Revised)

Talvey (talquetamab) (Revised)

Zoryve (roflumilast) (Revised)

Tyenne (tocilizumab) subcutaneous (Revised)

Tyenne (tocilizumab) subcutaneous (Revised)

Talvey (talquetamab) (Revised)

Sutent (sunitinib) (Revised)

Simponi (golimumab) (Revised)

Rinvoq (upadacitinib) LQ Oral Solution (Revised)

Rinvoq (upadacitinib) Extended Release Tablet (Revised)

Wound Care - MEDICAID - LOUISIANA (Revised)

Yulithira (everolimus) (New)

Uterine Fibroid Surgical Treatments - MEDICAID - KENTUCKY (Revised)

Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - VIRGINIA (New)

Thiopurine S-Methyltransferase Enzyme Activity Testing - MEDICAID - INDIANA (New)

Spinal Fusion and Stabilization Surgery - MEDICAID - OHIO (New)

Spinal Decompression Surgery - MEDICAID - VIRGINIA (New)

Spinal Decompression Surgery - MEDICAID - SOUTH CAROLINA (Revised)