Medicare AdvantagePrior AuthMedium impact
Voquezna® (vonoprazan) (Revised)
Humana·Gastroenterology, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jul 23, 2026
Summary
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.
Action Required
By January 1, 2025: Billing and pharmacy teams must implement prior authorization requirement for all Voquezna (vonoprazan) claims for Medicare Advantage members. Establish workflow to verify: (1) For erosive esophagitis: 8-week PPI trial failure + endoscopy confirmation + gastroenterologist prescription + 8-week treatment attestation; (2) For H. pylori: positive test + combination antibiotic therapy + Talicia trial/contraindication documentation; (3) For non-erosive GERD: 6-month symptom history + 4+ days/week heartburn + dual PPI failure documentation + 4-week max treatment attestation. Update pharmacy system to flag Voquezna prescriptions for MA members and route to prior auth team. Coordinate with providers to ensure prescriptions include all required documentation. Flag any prescriptions exceeding 8 months for erosive esophagitis or 4 weeks for GERD as non-compliant. Claims submitted without prior authorization will be denied. Update internal training materials with new criteria and communicate to all dispensing locations.