MedicaidPrior AuthMedium impact
Ziihera (zanidatamab-hrii) (New)
Humana·LA · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Louisiana Medicaid is implementing a new prior authorization policy for Ziihera (zanidatamab-hrii), a specialized cancer therapy for HER2-positive biliary tract cancer. Effective November 1, 2025, all claims for this drug require prior authorization and must meet specific clinical criteria including prior gemcitabine-based therapy, HER2-positive confirmation by FDA-approved test, and monotherapy use only. Claims that do not meet these criteria or show disease progression will be denied.
Action Required
By November 1, 2025: Billing team and oncology providers must implement prior authorization requirement for all Ziihera (zanidatamab-hrii) claims submitted to Humana Louisiana Medicaid. Before submitting claims, obtain prior authorization by verifying: (1) member has unresectable or metastatic biliary tract cancer diagnosis; (2) HER2-positive status documented via FDA-approved test (IHC 3+); (3) at least one prior line of therapy (gemcitabine-based regimen) is documented; (4) drug will be used as monotherapy only; and (5) no prior disease progression on Ziihera. Update billing system to flag all Ziihera submissions for manual prior auth review or electronic submission through Humana's PAL system (www.humana.com/PAL). Train providers to include HER2 testing documentation and prior treatment history on PA requests. Failure to obtain prior authorization will result in claim denials. For medical billing inquiries, direct providers to Humana's Preauthorization and Notification List (PAL) for applicable coding information.