Medicare AdvantagePrior AuthHigh impact
Dasatinib products (Revised)
Humana·Oncology, Hematology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Aug 12, 2026
Summary
Humana updated its dasatinib products (Sprycel, Phyrago, generic dasatinib) prior authorization policy effective January 1, 2026, with a revision date of April 22, 2026. The policy defines coverage criteria for five indications: adult CML, adult ALL, advanced GIST, pediatric CML, and pediatric ALL. Key requirements include Philadelphia chromosome positivity for most indications, specific disease phase/progression criteria, exclusions for certain mutations (T315I/A, F317L/V/I/C, V299L), and mandatory intolerance/contraindication documentation for brand products.
Action Required
By December 31, 2025: Billing and clinical teams must implement prior authorization workflow for all dasatinib product claims (Sprycel, Phyrago, generic dasatinib) under Humana Medicare Advantage plans. Update authorization software to require documentation of: (1) Philadelphia chromosome status and disease phase/indication, (2) disease progression history and prior treatments, (3) absence of T315I/A, F317L/V/I/C, or V299L mutations, and (4) for brand products, documentation of intolerance or contraindication to generic dasatinib. Configure system to auto-deny claims if exclusion criteria (disease progression on dasatinib or presence of specified mutations) are documented. Train prior auth staff and providers on the five distinct indication pathways and their specific approval criteria. Update encounter templates to capture required clinical documentation. Any claim submitted without complete prior authorization documentation will be denied by Humana effective January 1, 2026.