Medicare AdvantagePrior AuthMedium impact
Afinitor/Afinitor Disperz (everolimus) (Revised)
Humana·Oncology, Neurology, Pediatrics·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Sep 15, 2026
Summary
Humana Medicare Advantage updated its prior authorization policy for Afinitor/Afinitor Disperz (everolimus) effective January 1, 2026, with a revision dated February 25, 2026. The policy maintains prior authorization requirements across six oncology and neurology indications, with a consistent requirement that members must demonstrate intolerance or contraindication to generic everolimus before brand approval. All indications exclude members who have experienced disease progression while on everolimus therapy.
Action Required
By January 1, 2026: Billing and prior authorization teams must update internal policy references to the revised Afinitor/Afinitor Disperz policy (effective 1/1/2026, revision 2/25/2026) in all systems and workflows. For any prior authorization requests for everolimus products on Humana Medicare Advantage plans: (1) Verify member has documented intolerance or contraindication to generic everolimus before approving brand Afinitor/Afinitor Disperz; (2) Confirm the member's diagnosis matches one of the six covered indications (TSC-associated partial-onset seizures, advanced RCC, neuroendocrine tumors, SEGA with TSC, angiomyolipoma with TSC, or HR+/HER2- metastatic breast cancer); (3) Deny requests for members with documented disease progression on everolimus therapy; (4) Route requests through the prior authorization system with clinical documentation supporting medical necessity. Update PA templates and provider communications to reflect these requirements. Failure to obtain prior authorization or to verify exclusion criteria will result in claim denials.