Medicare AdvantagePrior AuthMedium impact
Fosaprepitant products (Emend, Focinvez) (Revised)
Humana·Oncology, Hematology, Pharmacy·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 1, 2026
Summary
This is a revised Medicare Advantage prior authorization policy for fosaprepitant products (Emend, Focinvez) effective January 1, 2026, with a revision date of June 24, 2026. Coverage requires the medication be used for prophylaxis (not treatment) of chemotherapy-induced nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy, AND must be part of a regimen that includes both a corticosteroid and a 5-HT3 antagonist, or the patient must have a contraindication to one of these drug classes. Prior authorization is required before dispensing.
Action Required
Before January 1, 2026: Billing and clinical teams must implement prior authorization requirements for all fosaprepitant claims (Emend powder, Emend IV solution, Focinvez). Update billing system and pharmacy systems to require PA submission before claim processing for Medicare Advantage members. Train staff to verify that prescriptions meet all three approval criteria: (1) prophylaxis indication only, (2) HEC or MEC chemotherapy use, and (3) concurrent use of both corticosteroid AND 5-HT3 antagonist, OR documented contraindication to one of these agents. Verify contraindication documentation before approving claims. Contact Humana at www.humana.com/PAL for current PA submission procedures and medical billing codes. Claims submitted without prior authorization or failing to meet criteria will be denied for Medicare Advantage beneficiaries.