Medicare AdvantagePrior AuthMedium impact
Faslodex (fulvestrant) (Revised)
Humana·KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Aug 6, 2026
Summary
Humana revised its Faslodex (fulvestrant) prior authorization policy effective January 1, 2025, with updates published September 24, 2025. The policy now covers fulvestrant as monotherapy for HR-positive, HER2-negative advanced breast cancer in treatment-naive or endocrine-resistant patients, and as combination therapy with CDK 4/6 inhibitors for initial or post-progression treatment. Prior authorization is required for all uses across Medicare, Kentucky Medicaid, and South Carolina Medicaid.
Action Required
By January 1, 2025 (retroactively by September 24, 2025): Billing team and providers must implement prior authorization requirements for all Faslodex/fulvestrant claims for Medicare, Kentucky Medicaid, and South Carolina Medicaid members. (1) Update billing system to flag all fulvestrant intramuscular syringe claims for prior auth submission before claim processing. (2) Providers must document: HR+/HER2- status, menopausal status or ovarian ablation/suppression confirmation, treatment history (treatment-naive vs. endocrine-resistant), and whether fulvestrant is used as monotherapy or combined with a CDK 4/6 inhibitor (abemaciclib, palbociclib, or ribociclib). (3) Front desk and prior auth staff must verify member eligibility on these three plans and route all fulvestrant requests to Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL. (4) Obtain approval confirmation before dispensing; claims submitted without prior authorization will be denied. Approval duration is plan year or as determined by clinical review.