Medicare AdvantagePrior AuthMedium impact
Faslodex (fulvestrant) (Revised)
Humana·KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has updated their prior authorization policy for Faslodex (fulvestrant) intramuscular injections used for hormone receptor-positive breast cancer treatment. This policy applies to Medicare and Medicaid plans in Kentucky and South Carolina, requiring specific criteria to be met for both monotherapy and combination therapy approaches.
Action Required
By January 1, 2025: Billing team must ensure prior authorization is obtained for all Faslodex (fulvestrant) intramuscular injections for Medicare and Medicaid patients in Kentucky and South Carolina. Verify patient meets required criteria including hormone receptor-positive status, HER2-negative status for certain indications, post-menopausal status or ovarian suppression, and appropriate treatment history. Update billing system to flag these cases for prior auth review before claim submission.