Medicare AdvantagePrior AuthMedium impact
Brukinsa™ (zanubrutinib) (Revised)
Humana·Hematology, Oncology, Pharmacy·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Brukinsa (zanubrutinib) prior authorization policy effective April 22, 2026. The policy clarifies coverage criteria across five lymphoid malignancies with specific requirements for prior therapy, monotherapy use, and combination therapy depending on indication. Key change: Follicular lymphoma now requires combination with obinutuzumab after 2+ prior lines; all indications exclude coverage if patient experienced disease progression on Brukinsa.
Action Required
By April 22, 2026: Billing and clinical teams must implement prior authorization requirements for all Brukinsa requests under Humana Medicare Advantage. Specific actions: (1) Update billing system to require PA for mantle cell lymphoma (must verify ≥1 prior therapy + monotherapy use), CLL/SLL (diagnosis only), marginal zone lymphoma (≥1 prior line + anti-CD20 regimen + monotherapy), Waldenström's macroglobulinemia (monotherapy only), and follicular lymphoma (≥2 prior lines + obinutuzumab combination). (2) Add documentation checklist to provider encounter forms confirming: diagnosis, prior treatment history, therapy line, and combination status. (3) Train prior authorization staff to deny any request showing prior disease progression on Brukinsa per exclusion criteria. (4) Update internal coding guidelines to capture complete treatment history for all pharmacy PA submissions. Failure to obtain prior authorization will result in claim denials. Reference CMS guidance if conflicts arise with state-specific Medicare rules.