Medicare AdvantagePrior AuthMedium impact
Vijoice® (alpelisib) (Revised)
Humana·Pediatrics, Genetics, Dermatology +1 more·Medicare Advantage
Effective date
Jul 27, 2022
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Vijoice® (alpelisib) prior authorization policy effective February 25, 2026. The policy covers this PI3K inhibitor for adult and pediatric patients (age 2+) with severe manifestations of PIK3CA-Related Overgrowth Spectrum (PROS) requiring systemic therapy, contingent on meeting three clinical criteria: confirmed PIK3CA gene mutation, PROS diagnosis, and physician-documented severe/life-threatening disease manifestations. All three Vijoice formulations (50mg, 125mg, 250mg tablets and 50mg granule packets) require prior authorization before dispensing.
Action Required
Before February 25, 2026: Billing and pharmacy teams must implement prior authorization requirements for all Vijoice (alpelisib) claims for Medicare Advantage members. (1) Update pharmacy billing system to flag Vijoice prescriptions for mandatory prior authorization. (2) Create/update prior auth submission checklist requiring: patient PROS diagnosis documentation, confirmed PIK3CA gene mutation results, and physician attestation of severe/life-threatening disease manifestations requiring systemic therapy. (3) Notify contracting providers that Vijoice prescriptions cannot be filled without Humana prior authorization approval; claims submitted without prior auth will be denied. (4) Train pharmacy staff and prior auth staff on the three approval criteria and renewal process (approved for plan year duration with renewal at plan year boundary). (5) Ensure EMR/pharmacy system is updated to capture all three required approval criteria for documentation. Failure to obtain prior authorization before dispensing will result in claim denials and potential member balance billing issues.