Medicare AdvantagePrior AuthMedium impact
Retevmo (selpercatinib) (Revised)
Humana·Oncology, Pulmonology, Endocrinology·Medicare Advantage
Effective date
Jul 8, 2020
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Retevmo (selpercatinib) prior authorization policy on February 25, 2026, with a review date of January 29, 2026. This is a pharmacy coverage policy requiring prior authorization for selpercatinib across four specific cancer indications: RET fusion-positive non-small cell lung cancer, RET-mutant medullary thyroid cancer, RET fusion-positive thyroid cancer (radioactive iodine-refractory), and RET fusion-positive solid tumors. All approvals are limited to 6-month initial and renewal periods, with disease progression on therapy as a key exclusion criterion.
Action Required
By March 31, 2026: Billing and prior authorization teams must verify this is the current version on Humana's website (note: printed copies are uncontrolled). Update internal prior authorization workflows and clinical decision support systems to reflect the February 25, 2026 revision. For any Retevmo/selpercatinib claims for Medicare Advantage members, ensure prior authorization is obtained before claim submission by: (1) verifying the member meets all applicable criteria for their specific cancer indication, (2) confirming RET fusion/mutation status is documented in medical records, (3) confirming monotherapy/single-agent use, and (4) confirming no disease progression has occurred on prior Retevmo therapy. Communicate the 6-month approval duration to providers and set up renewal tracking. Per the policy disclaimer, state and federal law and CMS coverage determinations (NCD/LMRP/LCD) take precedence—verify no conflicting CMS guidance exists before finalizing processes. Claims submitted without prior authorization or that do not meet criteria will be denied.