Medicare AdvantagePrior AuthMedium impact
Calquence® (acalabrutinib) (Revised)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Apr 22, 2026
We identified it
Aug 12, 2026
Summary
Humana revised its Calquence (acalabrutinib) pharmacy coverage policy effective April 22, 2026. The policy maintains prior authorization requirements for two key indications: mantle cell lymphoma (with specific treatment pathway criteria) and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Both indications exclude coverage if the member experiences disease progression while on or following Calquence. The policy requires verification of diagnosis, prior therapy history, and treatment combinations before approval.
Action Required
By April 22, 2026: Billing team must update prior authorization protocols for Calquence claims submitted to Humana Medicare Advantage plans. (1) Verify member diagnosis (mantle cell lymphoma OR CLL/SLL) before submitting requests. (2) For mantle cell lymphoma: Confirm either (a) prior therapy with monotherapy intent OR (b) previously untreated disease with ineligibility for HSCT and combination therapy with bendamustine/rituximab followed by maintenance therapy. (3) For CLL/SLL: Confirm diagnosis only; criteria are simplified. (4) CRITICAL EXCLUSION: Flag and DENY approval if member has experienced disease progression while on or following Calquence - do not submit these requests. (5) Update EMR/billing system templates to capture these criteria on encounter forms and prior authorization submission screens. (6) Brief providers and clinical staff on these requirements. Failure to obtain prior authorization before dispensing will result in claim denials. Reference Humana's PAL system at www.humana.com/PAL for provider claim codes.