Medicare AdvantagePrior AuthMedium impact
Kisqali (ribociclib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jan 1, 2024
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has revised their prior authorization policy for Kisqali (ribociclib), a breast cancer medication. The policy now covers three specific indications with detailed criteria for hormone receptor-positive, HER2-negative breast cancer patients, requiring 6-month approval periods.
Action Required
Immediately: Billing team must ensure prior authorization is obtained for all Kisqali (ribociclib) prescriptions for Medicare Advantage patients. Verify patients meet specific criteria: HR-positive/HER2-negative breast cancer diagnosis, appropriate combination therapy (with aromatase inhibitor or fulvestrant), and no prior CDK 4/6 inhibitor progression. Submit reauthorization requests every 6 months. Claims will be denied without proper prior authorization.