Medicare AdvantagePrior AuthMedium impact
Gattex® (teduglutide) (Revised)
Humana·KY, SC · Gastroenterology, Pediatrics, Palliative Care·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 22, 2026
Summary
Humana revised its Gattex® (teduglutide) prior authorization policy effective July 22, 2026 for Medicare and Medicaid (Kentucky and South Carolina). The policy maintains coverage for Short Bowel Syndrome patients dependent on parenteral support, with streamlined renewal criteria requiring documented decreases in parenteral support volume. Initial and renewal approvals remain 3 months each.
Action Required
By July 22, 2026: Billing and prior authorization teams must update internal systems and clinical review protocols to reflect the revised renewal criteria for Gattex®. Key changes: (1) Renewal now requires documentation of decreased parenteral support volume (mL) from baseline weekly requirement at treatment start—actual volume changes must be documented; (2) discontinuation of parenteral support qualifies as volume decrease for continuation approval. Action items: Update PA request templates to require baseline parenteral support volumes; train clinical reviewers on new volume decrease documentation requirements; update billing software to flag Gattex® claims for 3-month PA cycles (initial and renewal); communicate to ordering providers that continuation requests must include comparative parenteral support volume documentation. Failure to obtain prior authorization will result in claim denials. This applies only to Kentucky and South Carolina Medicaid and Medicare members.