Medicare AdvantagePrior AuthMedium impact
Jaypirca (pirtobrutinib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Apr 26, 2023
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has updated its prior authorization policy for Jaypirca (pirtobrutinib) effective April 26, 2023, with a revision date of April 22, 2026. The policy covers two indications: relapsed/refractory mantle cell lymphoma (after ≥2 prior lines including BTK inhibitor) and CLL/SLL (after prior covalent BTK inhibitor), both requiring monotherapy use and prior authorization. The revision clarifies coverage criteria and approval duration aligned to plan year.
Action Required
By April 22, 2026 (next review date): Billing and prior authorization teams must verify current policy version on Humana website before processing any Jaypirca (pirtobrutinib) requests. For all new Jaypirca claims: (1) Verify member has Medicare Advantage coverage with Humana; (2) Confirm diagnosis is either relapsed/refractory MCL (with ≥2 prior systemic therapy lines including BTK inhibitor) OR CLL/SLL (with prior covalent BTK inhibitor exposure); (3) Confirm prescribing is for monotherapy only (not combination); (4) Submit prior authorization request before claim submission; (5) Document all criteria verification in claim notes. Update billing system workflow to flag Jaypirca as requiring prior auth for Medicare Advantage plans. Train staff that claims submitted without prior authorization will be denied. Note: Prescribing information was revised December 2025—verify alignment with current drug labeling before processing.