Medicare AdvantagePrior AuthMedium impact
Tyenne (tocilizumab) subcutaneous (Revised)
Humana·Rheumatology, Pediatrics, Internal Medicine·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 23, 2026
Summary
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.
Action Required
By January 1, 2026: Billing team must implement prior authorization requirements for all Tyenne (tocilizumab) subcutaneous claims in the billing system. For rheumatoid arthritis, polyarticular JIA, and systemic JIA requests, verify patient has documented prior therapy failure, contraindication, or intolerance with at least 2 of the specified agents (adalimumab products, Enbrel, or Rinvoq). For giant cell arteritis, verify prior Rinvoq failure/contraindication. Confirm age requirements are met for each indication (18+ for RA and GCA; 2+ for juvenile indications). Update prior auth workflow to route requests to medical director review before claim processing. Train billing staff and providers that claims submitted without prior authorization or missing required clinical documentation will be denied. Reference Humana's PAL system at www.humana.com/PAL for specific medical coding requirements.