Medicare AdvantagePrior AuthMedium impact
Balversa (erdafitinib) (Revised)
Humana·Oncology, Pharmacy·Medicare Advantage
Effective date
Feb 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Medicare Advantage prior authorization policy for Balversa (erdafitinib) effective February 25, 2026. The policy maintains three strict approval criteria: locally advanced/metastatic urothelial carcinoma with documented FGFR3 genetic alterations, and use as subsequent therapy after at least one prior systemic therapy line including a PD-1/PD-L1 inhibitor. Initial and renewal approvals are limited to 6-month periods, and billing teams must verify genetic testing documentation is in the medical record before claim submission.
Action Required
By February 25, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization workflows to require all three approval criteria be documented before submitting claims for Balversa (erdafitinib); (2) Verify medical records contain specific FGFR3 genetic alteration documentation (R248C, S249C, G370C, Y373C mutations or FGFR3-TACC3v1/TACC3v2/TACC3/BAIAP2L1 fusions) before authorization requests; (3) Confirm patients have received at least one prior systemic therapy line including a PD-1 or PD-L1 inhibitor (avelumab, pembrolizumab, or equivalent); (4) Set claim system to enforce 6-month initial approval periods and 6-month renewal periods; (5) Create internal checklist for front-end staff to confirm all three criteria are met before routing to prior authorization department. Failure to obtain prior authorization with complete documentation will result in claim denials for Medicare Advantage members.