Medicare AdvantagePrior AuthHigh impact
Zelboraf (vemurafenib) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Zelboraf (vemurafenib) prior authorization policy effective January 1, 2026, with updates finalized April 22, 2026. The policy now covers two indications: unresectable/Stage IV metastatic melanoma with documented BRAF V600 mutation (as monotherapy or with Cotellic), and Erdheim-Chester Disease with BRAF V600 mutation (monotherapy only). Critical exclusions include concomitant use of specific immunotherapies and BRAF/MEK inhibitors, and prior disease progression on Zelboraf or anti-BRAF/MEK combination therapy. Billing teams must verify BRAF mutation documentation and drug interaction status before claim submission to avoid denials.
Action Required
By January 1, 2026: Billing and authorization teams must implement the following prior authorization requirements for all Zelboraf (vemurafenib) claims on Humana Medicare Advantage plans: (1) Verify member meets applicable criteria—unresectable/Stage IV metastatic melanoma OR Erdheim-Chester Disease with documented BRAF V600 activating mutation; (2) Confirm Zelboraf is prescribed as monotherapy or, for melanoma only, in combination with Cotellic (cobimetinib); (3) SCREEN FOR EXCLUSIONS—deny or flag for medical review if member is concurrently on ipilimumab, nivolumab, pembrolizumab, dabrafenib, trametinib, encorafenib, or binimetinib; (4) Verify no prior disease progression documented on Zelboraf or prior anti-BRAF/MEK combination therapy. Update billing system to require BRAF mutation test documentation in claims submission. Train authorization staff to cross-reference drug interaction lists before approval. Document all prior auth decisions with clinical justification. Failure to verify exclusion criteria will result in claim denials and potential rework.