Medicare AdvantagePrior AuthMedium impact
Trastuzumab products (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana has revised its prior authorization requirements for trastuzumab products (cancer medications like Herceptin) for Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. The policy establishes step therapy requirements where cheaper biosimilars (Trazimera or Kanjinti) must be tried first before approving brand-name versions for breast and gastric cancer treatment.
Action Required
Before January 1, 2026: Oncology billing teams must update prior authorization workflows for trastuzumab products. Ensure documentation shows HER2-positive status and, for brand-name products, document intolerance or contraindication to Trazimera or Kanjinti. Update EMR templates to capture required criteria. Note: Step therapy doesn't apply to Medicare Part B continuation therapy within 365 days or Florida Medicaid requests.