MedicaidPrior AuthMedium impact
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) (New)
Humana·OH · Oncology·Medicaid
Effective date
Feb 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf), a subcutaneous solution for HER2-positive breast cancer treatment. The policy requires prior authorization for all three indications: early stage breast cancer (neoadjuvant), early stage breast cancer (adjuvant), and metastatic breast cancer, with specific criteria including HER2-positive documentation and appropriate combination therapy protocols.
Action Required
Before February 1, 2026: Billing and clinical teams must implement prior authorization requirements for all Phesgo prescriptions for Medicaid Ohio patients. Ensure providers document HER2-positive status, appropriate breast cancer staging, and prescribed combination therapy regimens before submitting requests. Update EMR templates to include required clinical criteria and treatment cycle limitations (maximum 52 weeks or 18 cycles for neoadjuvant/adjuvant therapy). Claims will be denied without proper prior authorization.