Medicare AdvantagePrior AuthMedium impact
Tykerb (lapatinib) (Revised)
Humana·Oncology, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana revised its Tykerb (lapatinib) prior authorization policy effective January 1, 2023, with a revision date of November 26, 2025. The policy maintains prior authorization requirements for brand Tykerb (requiring documented intolerance/contraindication to generic lapatinib) and defines specific clinical criteria for HER2-positive breast cancer treatment. Key criteria include advanced/metastatic HER2-positive disease with prior anthracycline and taxane therapy, or first-line use with aromatase inhibitors for hormone receptor-positive disease. Members with disease progression on Tykerb are excluded from coverage.
Action Required
By December 31, 2025: Billing and clinical teams must ensure all Tykerb (lapatinib) requests—especially brand formulations—include prior authorization submission with documentation of: (1) HER2-positive status per ASCO-CAP guidelines (IHC 3+, IHC 2+ with ISH confirmation, or ISH dual-probe criteria), (2) prior anthracycline and taxane exposure OR first-line use with aromatase inhibitor for HR-positive disease, and (3) confirmation of no prior disease progression on Tykerb. Update prior authorization submission templates and provider order forms to capture these clinical details. Flag any requests for brand Tykerb without documented intolerance/contraindication to generic lapatinib for denial. Pharmacy staff should verify member meets all criteria before dispensing. Claims submitted without proper prior authorization will be denied by Humana Medicare Advantage plans.