Medicare AdvantagePrior AuthMedium impact
Piqray (alpelisib) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has updated prior authorization requirements for Piqray (alpelisib) effective January 1, 2025. This oral cancer medication requires prior auth for advanced/metastatic HR-positive, HER2-negative breast cancer with PIK3CA mutation, and must be used in combination with fulvestrant after endocrine therapy failure.
Action Required
By January 1, 2025: Billing team must ensure prior authorization is obtained for all Piqray (alpelisib) prescriptions for Humana Medicare Advantage members. Verify patient meets all three criteria: (1) advanced/metastatic HR-positive, HER2-negative breast cancer with PIK3CA mutation confirmed by FDA-approved test, (2) disease progression after endocrine therapy, and (3) combination use with fulvestrant. Update pharmacy billing system to flag this medication for prior auth requirements. Claims will be denied without proper authorization.