Medicare AdvantagePrior AuthMedium impact
Nerlynx (neratinib) (Revised)
Humana·Oncology·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Nerlynx (neratinib) pharmacy coverage policy effective January 1, 2026. This is a prior authorization policy for Medicare Advantage members with HER2-positive breast cancer (early-stage in extended adjuvant setting or metastatic). Key requirements include documented HER2+ disease, completion of prior trastuzumab therapy (early-stage), and specific combination therapy for metastatic cases. The policy excludes members with disease progression on Nerlynx and limits early-stage treatment to one year maximum.
Action Required
By January 1, 2026: Billing and prior authorization teams must implement the following: (1) Update billing system to require prior authorization for all Nerlynx (neratinib) claims for Medicare Advantage members; (2) Create or update PA request templates to capture: HER2+ status documentation, prior trastuzumab therapy completion (for early-stage), treatment setting (extended adjuvant vs. metastatic), and for metastatic cases, confirmation of two or more prior anti-HER2 regimens and concurrent capecitabine use; (3) Configure system edits to flag and deny claims for members with documented disease progression on Nerlynx or early-stage patients exceeding 12 months of treatment; (4) Brief clinical staff and providers on revised criteria, particularly the requirement for two prior anti-HER2 regimens in metastatic setting and one-year treatment limitation for early-stage disease. Update encounter templates and PA forms to reflect these exclusion criteria. Failure to obtain proper prior authorization will result in claim denials.