MedicaidPrior AuthMedium impact
Enhertu (fam-trastuzumab deruxtecan-nxki) (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Jun 1, 2026
We identified it
Jun 24, 2026
Summary
New prior authorization policy for Enhertu (fam-trastuzumab deruxtecan-nxki) intravenous solution for Ohio Medicaid patients with specific cancer diagnoses including HER2-positive breast cancer, HER2-low/ultralow breast cancer, gastric adenocarcinoma, HER2-mutant lung cancer, and HER2-positive solid tumors. Each indication has specific criteria that must be met for approval.
Action Required
Before June 1, 2026: Billing team must update prior authorization requirements for Enhertu (fam-trastuzumab deruxtecan-nxki) for Ohio Medicaid patients. Providers must document specific HER2 status, cancer type, prior treatments, and treatment plans according to indication-specific criteria. Update EMR templates to capture required documentation elements including HER2 testing results, prior therapy history, and monotherapy vs combination therapy plans. Claims will be denied without proper prior authorization.