MedicaidPrior AuthMedium impact
Ziihera (zanidatamab-hrii) (New)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Nov 1, 2025
We identified it
Jun 25, 2026
Summary
Humana Indiana Medicaid now covers Ziihera (zanidatamab-hrii) for previously treated, unresectable or metastatic HER2-positive biliary tract cancer under a prior authorization requirement. This is a new pharmacy coverage policy effective November 1, 2025, requiring four approval criteria: unresectable/metastatic BTC diagnosis, HER2-positive status (IHC 3+), at least one prior line of therapy, and monotherapy use. Claims will be denied if the member has experienced disease progression on Ziihera.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirements for Ziihera (zanidatamab-hrii) in the billing system for all Indiana Medicaid patients. Before submitting claims: (1) Verify member meets all four approval criteria (unresectable/metastatic BTC, HER2-positive IHC 3+, prior gemcitabine-based therapy, monotherapy use); (2) Obtain prior authorization from Humana Indiana Medicaid; (3) Document HER2 test results and prior treatment history in claim submission; (4) Confirm member has not progressed on Ziihera. Update encounter forms and provider templates to capture required clinical documentation. Route all Ziihera requests through prior authorization process—claims submitted without prior auth will be denied. Providers should refer to www.humana.com/PAL for applicable preauthorization and notification lists. Flag any cases with prior disease progression on Ziihera as non-approvable.