MedicaidPrior AuthMedium impact
Margenza (margetuximab-cmkb) (New)
Humana·IN · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jun 24, 2026
Summary
New prior authorization policy for Margenza (margetuximab-cmkb) for Indiana Medicaid members with metastatic HER2-positive breast cancer. Requires specific criteria including prior anti-HER2 therapies and combination with approved chemotherapy regimens.
Action Required
Before November 1, 2025: Billing team must implement prior authorization requirements for Margenza (margetuximab-cmkb) for Indiana Medicaid members. Update billing system to flag metastatic breast cancer cases requiring verification of HER2-positive status, two prior anti-HER2 therapies (including one in metastatic setting), and combination with approved chemotherapy (gemcitabine, eribulin, vinorelbine, capecitabine). Visit www.humana.com/PAL for specific medical and procedural codes.