Medicare AdvantagePrior AuthMedium impact
Gavreto (pralsetinib) (Revised)
Humana·Oncology·Medicare Advantage
We identified it
Sep 15, 2026
Summary
Humana revised its Gavreto (pralsetinib) prior authorization policy for Medicare Advantage members on March 25, 2026. The policy maintains prior authorization requirements for two oncology indications: metastatic RET fusion-positive non-small cell lung cancer and metastatic/advanced RET fusion-positive thyroid cancer in patients 12+. Both approvals are valid for 6-month intervals with renewal required. Members with prior disease progression on RET inhibitors are excluded from coverage.
Action Required
Immediately: Billing and prior authorization teams must verify this is the current Gavreto policy in your system by checking Humana's online policy portal at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5ce002. Update any internal prior auth workflows to reflect the March 25, 2026 revision date. For all Gavreto claims for Medicare Advantage members: (1) Ensure documentation confirms RET fusion-positive status via FDA-approved testing; (2) Verify monotherapy use (not combination therapy); (3) For lung cancer: confirm metastatic NSCLC diagnosis; (4) For thyroid cancer: confirm age 12+, metastatic/advanced disease, and documentation that radioactive iodine is no longer effective (if appropriate); (5) Screen for exclusion: deny or deny renewal if member has disease progression on any RET inhibitor. Submit prior authorizations before dispensing. Initial approval is 6 months; plan for renewal submissions 6 months after approval date to avoid claim denials.