Medicare AdvantagePrior AuthMedium impact
Calquence® (acalabrutinib) (Revised)
Humana·Oncology, Hematology, Pharmacy·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its Calquence (acalabrutinib) prior authorization policy effective April 22, 2026. The policy maintains coverage for mantle cell lymphoma (MCL) with specific treatment history requirements and chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), with a key exclusion: members who have experienced disease progression while on or after Calquence are not approved. Billing teams must verify prior authorization requirements before dispensing and confirm members meet all clinical criteria.
Action Required
By April 22, 2026: Billing and pharmacy teams must update prior authorization workflows in pharmacy management systems to reflect the revised Calquence policy. (1) Implement mandatory prior auth verification for all Calquence claims on Humana Medicare Advantage plans; (2) Add clinical criteria verification: confirm member diagnosis (MCL or CLL/SLL) and treatment history before claim submission; (3) Flag and deny claims for members with documented disease progression while on or after Calquence—do not submit these for approval; (4) For MCL specifically: verify either (a) at least one prior therapy with monotherapy use, OR (b) previously untreated status with HSCT ineligibility and combination therapy plan; (5) Update pharmacy staff and billing team on new exclusion criteria. Pharmacy teams should consult the full policy at Humana's portal (www.humana.com/PAL) before processing any Calquence request. Failure to obtain prior authorization will result in claim denials.