Medicare AdvantagePrior AuthMedium impact
Exkivity (mobocertinib) (Revised)
Humana·Oncology, Pulmonology·Medicare Advantage
Effective date
Nov 17, 2021
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its prior authorization policy for Exkivity (mobocertinib), a targeted therapy for metastatic non-small cell lung cancer with EGFR exon 20 insertion mutations. The policy requires prior authorization with four clinical criteria: locally advanced/metastatic NSCLC, documented EGFR exon 20 insertion mutation, disease progression on platinum-based therapy, and use as single-agent subsequent therapy. Coverage is approved for 6-month periods with renewal available.
Action Required
By April 22, 2026 (revision date): Billing team and clinical staff must implement prior authorization requirements for all Exkivity (mobocertinib) claims submitted to Humana Medicare Advantage plans. Before submitting claims, verify member meets all four clinical criteria: (1) locally advanced or metastatic NSCLC diagnosis, (2) documented EGFR exon 20 insertion mutation confirmed by FDA-approved companion diagnostic test, (3) documented disease progression following platinum-based chemotherapy, and (4) Exkivity prescribed as single-agent subsequent line therapy. Update billing software and prior authorization submission templates to include these four criteria. Educate oncology providers to document the mutation status and prior chemotherapy response in all patient records before Exkivity initiation. Route all Exkivity requests through Humana's PAL (Preauthorization and Notification List) portal at www.humana.com/PAL. Include approval duration (6 months initial, 6 months renewal) in documentation. Flag any claims where member experienced disease progression on Exkivity for potential denial, as this is an exclusion criterion. Claims submitted without prior authorization or missing required clinical documentation will be denied by Humana.