Medicare AdvantagePrior AuthMedium impact
Cabometyx (cabozantinib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Jan 1, 2021
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Cabometyx (cabozantinib) prior authorization policy effective January 1, 2021, with the most recent revision dated February 25, 2026. The policy maintains coverage criteria for four oncology indications: hepatocellular carcinoma (requires prior sorafenib treatment), renal cell carcinoma (as monotherapy or with nivolumab), thyroid cancer (age 12+, post-VEGF therapy, radioactive iodine refractory/ineligible), and neuroendocrine tumors (age 12+). All indications require prior authorization and exclude coverage if disease progression occurs on cabozantinib.
Action Required
By March 25, 2026: Billing and clinical teams must update internal prior authorization workflows to align with the revised Cabometyx policy. (1) Update EHR/billing system templates to reflect the four covered indications and their specific criteria. (2) For hepatocellular carcinoma requests, ensure documentation of prior sorafenib treatment is obtained before PA submission. (3) For renal cell carcinoma, confirm whether Cabometyx is being used as monotherapy or in combination with nivolumab (Opdivo) as first-line therapy. (4) For thyroid cancer and NETs, verify patient age is 12 or older and obtain documentation of prior anti-VEGF therapy and radioactive iodine status. (5) Train providers and staff that disease progression on cabozantinib is an automatic exclusion triggering denial. (6) Route all Cabometyx requests through the prior authorization process per Humana's PAL portal at www.humana.com/PAL. Failure to follow these criteria and obtain prior authorization will result in claim denials for Medicare Advantage members.