Medicare AdvantagePrior AuthMedium impact
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jun 24, 2026
We identified it
Jun 25, 2026
Summary
Humana revised its Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) prior authorization policy effective June 24, 2026. The policy clarifies coverage criteria for HER2-positive breast cancer treatment in both adjuvant and metastatic settings, with step therapy requirements (prior trial of Kanjinti or Trazimera) now waived for Florida Medicaid requests. Key changes include explicit treatment combination pathways and exclusions for concomitant use with Kadcyla or gastric/GEJ/esophageal cancers.
Action Required
By June 24, 2026, the billing and clinical teams must: (1) Update prior authorization workflows in the billing system to reflect the new step therapy waiver for Florida Medicaid (no longer require prior Kanjinti or Trazimera trial for FL Medicaid claims); (2) Ensure prior auth requests for Herceptin Hylecta include documentation of HER2-positive status and specific treatment regimen (adjuvant vs. metastatic, chemotherapy combinations used); (3) Flag and deny claims showing concomitant use with Kadcyla (Exclusion #1) or for gastric/GEJ/esophageal carcinoma (Exclusion #2); (4) For Medicare Part B continuation-of-therapy requests within 365 days, disable step therapy requirement in system; (5) Notify providers in Florida Medicaid practices that prior step therapy documentation is no longer required, streamlining approvals. Failure to update workflows will result in claim delays or denials for non-compliant authorizations.