Medicare AdvantagePrior AuthMedium impact
Orserdu (elacestrant) (Revised)
Humana·Oncology, Pharmacy·Medicare Advantage
Effective date
Oct 22, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Orserdu (elacestrant) prior authorization policy effective October 22, 2025. The policy requires prior authorization for this selective estrogen receptor degrader (SERD) used to treat ER-positive, HER2-negative, ESR1-mutated advanced/metastatic breast cancer in patients with disease progression after at least one prior endocrine therapy line. Coverage is approved for 6-month initial and renewal periods when all four clinical criteria are met.
Action Required
By October 22, 2025: (1) Billing and authorization staff must update prior authorization workflows in the system to require PA submission for all Orserdu (elacestrant) claims under Humana Medicare Advantage plans. (2) Implement the four-criteria clinical checklist: confirm ER-positive/HER2-negative/ESR1-mutated status, document prior endocrine therapy line(s), verify single-agent use, and confirm advanced/metastatic disease stage. (3) Providers submitting Orserdu requests must attach FDA-approved ESR1 mutation test results and prior therapy documentation with all PA requests. (4) Update EMR/billing templates to flag Orserdu prescriptions for mandatory prior auth and to capture required clinical documentation fields. (5) Configure system to auto-approve initial authorizations for 6 months and set renewal reminders at 5.5-month mark for continuity. Failure to obtain prior authorization will result in claim denials. Reference Humana's Preauthorization and Notification List (PAL) at www.humana.com/PAL for current medical coding requirements.