Medicare AdvantagePrior AuthMedium impact
Zejula (niraparib) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Zejula (niraparib) prior authorization policy effective January 1, 2026, with updates finalized February 25, 2026. The policy covers niraparib for first-line and subsequent-line maintenance therapy in ovarian, fallopian tube, and primary peritoneal cancer patients with specific HRD-positive status and treatment response criteria. Key requirement: members with prior PARP inhibitor progression are excluded from coverage, and bevacizumab must be discontinued before initiating subsequent-line maintenance therapy.
Action Required
By January 1, 2026: Billing team must implement prior authorization workflow for Zejula (niraparib) claims under Humana Medicare Advantage. Update billing system to require clinical documentation of: (1) HRD-positive status (deleterious/suspected deleterious BRCA mutation or genomic instability via FDA-approved test), (2) complete or partial response to platinum-based chemotherapy, (3) confirmation of monotherapy use, and (4) absence of prior PARP inhibitor disease progression. For subsequent-line maintenance therapy, ensure bevacizumab discontinuation is documented before approval. Create prior authorization submission checklist for oncology providers and train billing staff on the two distinct coverage pathways (first-line vs. subsequent-line). Verify member eligibility and obtain prior authorization before claim submission. Rejection of claims lacking required documentation is expected per CMS guidelines.