Medicare AdvantagePrior AuthMedium impact
Gavreto (pralsetinib) (Revised)
Humana·Oncology, Pulmonology·Medicare Advantage
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Gavreto (pralsetinib) prior authorization policy effective March 25, 2026. The policy maintains coverage for RET fusion-positive metastatic non-small cell lung cancer and thyroid cancer (age 12+) as monotherapy, with prior authorization required. Key exclusion: members experiencing disease progression on RET inhibitors are not approved. Both initial and renewal approvals remain at 6-month intervals.
Action Required
By March 25, 2026: Billing and prior authorization teams must verify this policy is loaded in all PA systems and decision support tools. Update internal policy files to reflect revision date of March 25, 2026. For any Gavreto claims submitted for Medicare Advantage members: (1) Confirm diagnosis of metastatic or advanced RET fusion-positive cancer (NSCLC or thyroid); (2) Verify monotherapy use (no combination therapy); (3) Check for prior RET inhibitor progression (exclusion); (4) Obtain prior authorization before dispensing; (5) Note 6-month approval duration and plan for renewal requests. Communicate to prescribers that members with prior progression on pralsetinib or selpercatinib will not be approved. Update encounter documentation templates to capture RET fusion status and prior RET inhibitor therapy history.