Medicare AdvantagePrior AuthHigh impact
Enbrel (etanercept) (Revised)
Humana·Rheumatology, Dermatology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 22, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Enbrel (etanercept) effective January 1, 2026, with updates as of July 22, 2026. The policy establishes specific clinical criteria for coverage across six indications (ankylosing spondylitis, plaque psoriasis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and juvenile psoriatic arthritis), including age requirements, disease severity specifications, and prior therapy/contraindication/intolerance documentation requirements. All Enbrel prescriptions require prior authorization approval on a plan year basis before dispensing.
Action Required
By January 1, 2026 (or immediately if this date has passed): Billing and authorization teams must implement prior authorization requirements for all Enbrel (etanercept) products and formulations (kit, syringe, SureClick pen, Mini cartridge, solution) before submitting claims to Humana Medicare Advantage plans. For each indication, ensure prescribing providers or their staff document: (1) the specific diagnosis and severity level required by the policy; (2) the member's age meets minimum requirements (age 2, 4, or 18 depending on indication); (3) prior therapy history, contraindications, or intolerances as specified (e.g., NSAID trial for ankylosing spondylitis, DMARD trial for rheumatoid arthritis). Update EHR/billing system templates and prior authorization submission forms to capture these required elements before claim submission. Notify all prescribing providers (rheumatologists, dermatologists, pediatric rheumatologists per policy recommendation) of new/updated criteria. Train front desk and billing staff to route all Enbrel requests through prior authorization workflow. Claims submitted without prior authorization approval will be denied by Humana Medicare Advantage. Verify this is the current version on Humana's website before implementing, as the policy is subject to updates.