Medicare AdvantagePrior AuthHigh impact
Verzenio (abemaciclib) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jan 1, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Verzenio (abemaciclib) prior authorization policy effective January 1, 2024, with the most recent revision dated January 28, 2026. The policy outlines four approved indications for this CDK 4/6 inhibitor in HR-positive, HER2-negative breast cancer with specific prior authorization requirements, approval durations of 6 months for both initial and renewal periods, and exclusions including prior CDK 4/6 inhibitor progression and a 2-year treatment limit for early breast cancer cases.
Action Required
By January 28, 2026 (or immediately for current claims): (1) Billing team must implement prior authorization requirements for all Verzenio (abemaciclib) claims submitted to Humana Medicare Advantage plans; (2) Create or update billing system rules to require documentation of patient meeting all applicable criteria before claim submission for one of four indications: metastatic HR+/HER2- breast cancer with aromatase inhibitor as first-line therapy, metastatic disease with Faslodex after endocrine therapy progression, metastatic monotherapy after endocrine and chemotherapy progression, or early HR+/HER2- node-positive breast cancer; (3) Implement screening logic to identify and deny claims if member has prior CDK 4/6 inhibitor progression (palbociclib, ribociclib); (4) For early breast cancer cases, track cumulative Verzenio treatment duration and deny claims exceeding 2 years total; (5) Update provider order entry forms and prior authorization submission templates to require specific indication documentation and disease progression history; (6) Establish 6-month renewal prior authorization processes for both initial and renewal approval cycles; (7) Train clinical staff on exclusion criteria before submitting requests. Failure to obtain prior authorization or submit claims meeting specified criteria will result in claim denials from Humana Medicare Advantage.