Medicare AdvantagePrior AuthMedium impact
Myalept® (metreleptin) (Revised)
Humana·Endocrinology, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2017
We identified it
Jul 22, 2026
Summary
Humana updated its Myalept (metreleptin) prior authorization policy for Medicare Advantage members, effective January 1, 2017, with a recent revision dated July 22, 2026. The policy requires prior authorization for Myalept subcutaneous solution when treating congenital or acquired generalized lipodystrophy, with strict exclusions for partial lipodystrophy, liver disease (including NASH), HIV-related lipodystrophy, and generalized obesity. The policy emphasizes REMS program requirements, boxed warnings regarding anti-metreleptin antibodies and lymphoma risk, and approval duration determined by plan year or clinical review.
Action Required
By July 22, 2026 (revision effective date): Billing team and providers must update prior authorization workflows for Myalept (metreleptin) claims. (1) Update billing system to automatically flag Myalept requests for prior authorization review. (2) Verify member diagnosis is congenital OR acquired generalized lipodystrophy before submission—claims will be denied if member has partial lipodystrophy, liver disease (NASH), HIV-related lipodystrophy, diabetes/hypertriglyceridemia without concurrent generalized lipodystrophy, or generalized obesity not associated with congenital leptin deficiency. (3) Confirm prescriber and dispensing pharmacy are certified with the Myalept REMS Program before processing claims. (4) Update claims submission templates to require REMS Prescription Authorization Form documentation. (5) Educate providers that approval duration is plan year or as determined through clinical review. (6) Flag any claims showing signs of anti-metreleptin antibodies or lymphoma concerns for clinical review. Failure to obtain prior authorization or verify REMS compliance will result in claim denials.