Medicare AdvantagePrior AuthMedium impact
Orserdu (elacestrant) (Revised)
Humana·Oncology, Pharmacy·Medicare Advantage
Effective date
Oct 22, 2025
We identified it
Aug 6, 2026
Summary
Humana Medicare Advantage updated its prior authorization policy for Orserdu (elacestrant) effective October 22, 2025. This is a pharmacy coverage policy requiring prior authorization for this selective estrogen receptor degrader used to treat ER-positive, HER2-negative, ESR1-mutated advanced or metastatic breast cancer. The policy requires confirmation of specific clinical criteria including documented ESR1-mutation status and prior endocrine therapy failure before approval. Initial and renewal approvals are for 6-month periods.
Action Required
By October 22, 2025: Billing and pharmacy teams must implement prior authorization processes for Orserdu (elacestrant) prescriptions. Update pharmacy billing systems and prior auth workflows to require verification of all four clinical criteria before claim processing: (1) ER-positive, HER2-negative advanced/metastatic breast cancer diagnosis, (2) documented ESR1-mutation confirmed by FDA-approved test, (3) disease progression after at least one prior endocrine therapy line, and (4) Orserdu prescribed as single-agent subsequent therapy. Establish 6-month approval tracking for initial authorizations and renewals. Coordinate with oncology providers to ensure they submit required clinical documentation with prior auth requests. Flag claims missing ESR1-mutation testing documentation for denial prevention. Update front-end systems to route all Orserdu requests through prior authorization queue before adjudication.