Medicare AdvantagePrior AuthMedium impact
Zydelig® (idelalisib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jun 25, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Zydelig (idelalisib) prior authorization policy effective June 25, 2025. The key change is a new exclusion criterion: members who have experienced disease progression while on or following ANY PI3K inhibitor (including idelalisib and copanlisib) are now ineligible for coverage. This tightens access to the drug for relapsed/refractory CLL patients with prior PI3K inhibitor exposure.
Action Required
By June 25, 2025: Billing and prior authorization teams must update internal workflows and system flags to DENY Zydelig coverage for any Medicare Advantage member with documented disease progression on or after previous PI3K inhibitor therapy (idelalisib, copanlisib, or similar agents). Before submitting prior auth requests for Zydelig, verify patient's prior treatment history and specifically screen for prior PI3K inhibitor use and treatment response. If progression occurred on prior PI3K inhibitor, do not submit auth request as it will be denied. Educate providers and oncology staff that this exclusion applies to relapsed/refractory CLL patients only. Update PA submission templates to include required field: 'Prior PI3K inhibitor exposure: Yes/No' and 'Disease progression status on prior PI3K inhibitor.' Failure to screen for this exclusion will result in claim denials and rework.