Medicare AdvantagePrior AuthMedium impact
Erivedge® (vismodegib) (Revised)
Humana·Dermatology, Oncology·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Jun 25, 2026
Summary
Humana updated its Erivedge (vismodegib) prior authorization policy for Medicare Advantage members with basal cell carcinoma. The policy clarifies eligibility criteria requiring metastatic or locally advanced BCC (with recurrence or ineligibility for surgery/radiation), excludes members with disease progression on Erivedge or using it as neoadjuvant therapy, and maintains six-month approval durations for initial and renewal authorizations.
Action Required
By April 22, 2026: Billing and prior authorization teams must update internal policy documentation and authorization workflows to reflect the revised Erivedge criteria. Specifically: (1) Ensure prior authorization requests for Erivedge verify the member has metastatic BCC OR locally advanced BCC with documented disease recurrence post-surgery OR documented ineligibility for both surgery and radiation; (2) Add screening steps to reject authorization requests if member has experienced prior disease progression on Erivedge or if therapy is intended as neoadjuvant treatment; (3) Configure authorization system to issue initial approvals for six months and subsequent renewals for six-month periods. Update any internal prior auth templates or guidance documents. Staff should reference the full policy at the Humana PAL portal for any claim coding questions. Failure to apply these criteria may result in claim denials or improper authorizations.