Medicare AdvantagePrior AuthHigh impact
Enhertu (fam-trastuzumab deruxtecan-nxki) (Revised)
Humana·FL, KY, SC · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jan 1, 2023
We identified it
Jun 25, 2026
Summary
Humana revised its Enhertu (fam-trastuzumab deruxtecan-nxki) prior authorization policy effective January 1, 2023, with the most recent revision on March 25, 2026. The policy covers six oncology indications with specific clinical criteria, prior treatment requirements, and HER2 status specifications. Billing teams must verify prior authorization eligibility before claims submission across multiple Medicaid state programs and Medicare.
Action Required
Immediately: Billing and authorization teams must implement prior authorization requirements for Enhertu (HCPCS J9261) for all affected Medicaid states (FL, KY, SC) and Medicare members. Before submitting claims: (1) Verify member's cancer diagnosis matches one of six approved indications (HER2-positive/low/ultralow breast cancer, gastric/GEJ adenocarcinoma, HER2-mutant NSCLC, or HER2-positive solid tumors); (2) Confirm prior treatment criteria are met per indication type; (3) Ensure monotherapy vs. combination therapy aligns with policy; (4) Document HER2 status and testing method (IHC/ISH levels); (5) Screen for exclusions (disease progression on Enhertu); (6) Submit prior authorization request before dispensing. Update billing software to flag all J9261 claims requiring authorization review. Train providers to document treatment history, HER2 classification, and clinical rationale on all Enhertu orders. Failure to obtain prior authorization will result in claim denials.