All Insurance Policy Changes (Page 73)

Continuing from page 72. 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
Tecvayli (teclistamab-cqyv) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Tecvayli (teclistamab-cqyv) prior authorization policy effective July 22, 2026, for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains two coverage pathways: monotherapy for patients with ≥4 prior therapy lines including specific drug classes, or combination with daratumumab for patients with ≥1 prior line. Billing teams must ensure prior authorization is obtained before dispensing and verify patient eligibility under the specific treatment pathway (monotherapy vs. combination).
Low impact
Pyrukynd® (mitapivat) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage updated its Pyrukynd (mitapivat) prior authorization policy effective January 1, 2023, with a revision dated July 22, 2026. The policy requires prior authorization for Pyrukynd coverage in Medicare Advantage members with pyruvate kinase deficiency and hemolytic anemia, with three specific clinical criteria that must be met before approval. Billing teams must ensure all Pyrukynd claims include documented genetic testing results, hemoglobin levels, and meet exclusion criteria before submission.
Medium impact
Talvey (talquetamab) (Revised)
Humana·Effective Nov 22, 2023
This is a recent revision (July 22, 2026) of Humana's Talvey (talquetamab) prior authorization policy for multiple myeloma treatment. The policy applies to Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. All requests for Talvey require prior authorization and must meet strict clinical criteria: diagnosis of relapsed/refractory multiple myeloma, at least four prior lines of therapy including specific drug classes, and single-agent use only. Claims will be denied if the patient experiences disease progression while on Talvey.
Low impact
Voydeya™ (danicopan) tablet (Revised)
Humana·Effective Sep 25, 2024
This is a new Medicare Advantage prior authorization policy for Voydeya (danicopan) tablet, effective September 25, 2024. The policy requires prior authorization for Voydeya as add-on therapy to eculizumab or ravulizumab in PNH patients with clinically significant extravascular hemolysis. Billing teams must implement prior authorization requirements and validate that all four clinical criteria are met before claims are processed.
Medium impact
Vyloy (zolbetuximab-clzb) (Revised)
Humana·Effective Nov 27, 2024
Humana has established a new prior authorization policy for Vyloy (zolbetuximab-clzb), a specialized cancer immunotherapy for HER2-negative gastric and gastroesophageal junction adenocarcinoma. This policy applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid members and requires prior authorization before dispensing, with specific clinical criteria including CLDN18.2-positive tumor confirmation and first-line combination chemotherapy use.
Medium impact
Vyepti® (eptinezumab) (Revised)
Humana·Effective Jan 1, 2025
Humana updated its Vyepti (eptinezumab) prior authorization policy for Medicare Advantage plans effective January 1, 2025. The policy requires step therapy with both Emgality AND Qulipta before Vyepti approval for migraine prevention, with exceptions for Medicare Part B continuations and PDP/MA-only plans. Billing teams must ensure prior authorization is obtained and step therapy requirements are documented before claim submission.
Medium impact
Voquezna® (vonoprazan) (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its Voquezna (vonoprazan) prior authorization policy for Medicare Advantage members, effective January 1, 2025. This is a pharmacy coverage policy requiring prior authorization for three indications: erosive esophagitis (requires 8-week PPI trial failure + endoscopy confirmation), H. pylori infection (requires trial/contraindication to Talicia), and non-erosive GERD (requires 4-week max duration + prior PPI failure). Billing teams must implement prior auth verification before dispensing and ensure providers meet all documented criteria.
Medium impact
Tremfya (guselkumab) (Revised)
Humana·Effective Jan 1, 2025
Humana has issued a revised Medicare Advantage prior authorization policy for Tremfya (guselkumab) effective January 1, 2025, covering four indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. The policy requires prior authorization for all formulations (IV and subcutaneous) with specific clinical criteria based on diagnosis, age, weight, and prior treatment history. Billing teams must ensure all Tremfya claims include appropriate prior authorization before submission to avoid denials.
Medium impact
Ruconest (C1 esterase inhibitor, recombinant) (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its Ruconest (C1 esterase inhibitor, recombinant) prior authorization policy effective January 1, 2025, with a revision dated July 22, 2026. This policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires prior authorization for acute HAE attack treatment with eight specific approval criteria, including HAE diagnosis confirmation with lab documentation, specialist treatment requirement, and step-therapy waiver for Medicaid (but applies to Medicare Part B). Billing teams must ensure all prior authorization requirements are met before claims are submitted to avoid denials.
Medium impact
Qulipta (atogepant) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has established a prior authorization requirement for Qulipta (atogepant), a CGRP receptor antagonist used for migraine prevention in adults. The policy requires prior auth approval for initial and renewal periods, with specific dosage adjustments for patients with severe renal impairment or ESRD. This is a new pharmacy coverage policy effective January 1, 2025.
Medium impact
PiaSky® (crovalimab-akkz) injection (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its prior authorization policy for PiaSky® (crovalimab-akkz) injection, a complement C5 inhibitor for treating Paroxysmal Nocturnal Hemoglobinuria (PNH). The policy, effective January 1, 2025 and revised July 22, 2026, requires prior authorization for all PiaSky requests across Medicare and specific Medicaid programs (Florida, Kentucky, South Carolina, Virginia). Billing teams must verify patients meet all clinical criteria including confirmed PNH diagnosis via flow cytometry, weight ≥40 kg, clinical hemolysis or transfusion dependence, and for Medicare Part B, step therapy with Ultomiris unless continuing prior therapy within 365 days.
Medium impact
Firazyr (icatibant) (Revised)
Humana·Effective Jan 1, 2025
Humana's revised Firazyr (icatibant) policy for Kentucky Medicaid and Medicare clarifies prior authorization requirements for HAE treatment, distinguishing between HAE Type 1/2 (with C1-INH deficiency) and HAE Type 3 (with normal C1-INH). Key change: For Medicaid requests, step therapy requirements do not apply, meaning prior generic icatibant trial is NOT required for brand Firazyr approval.
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.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 73) | PolicyChanges.app

Tecvayli (teclistamab-cqyv) (Revised)

Pyrukynd® (mitapivat) (Revised)

Talvey (talquetamab) (Revised)

Voydeya™ (danicopan) tablet (Revised)

Vyloy (zolbetuximab-clzb) (Revised)

Vyepti® (eptinezumab) (Revised)

Voquezna® (vonoprazan) (Revised)

Tremfya (guselkumab) (Revised)

Ruconest (C1 esterase inhibitor, recombinant) (Revised)

Qulipta (atogepant) (Revised)

PiaSky® (crovalimab-akkz) injection (Revised)

Firazyr (icatibant) (Revised)

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)