Medicare AdvantagePrior AuthMedium impact
Margenza (margetuximab-cmkb) (Revised)
Humana·FL, KY, SC, VA · Oncology, Hematology·Medicaid
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Margenza (margetuximab-cmkb) prior authorization policy effective September 24, 2025. The policy maintains coverage for metastatic HER2-positive breast cancer patients who have received at least 2 prior anti-HER2 regimens (with one in metastatic setting) and are receiving Margenza in combination with specific chemotherapy agents. The revision date change suggests updates to clinical criteria, references, or administrative requirements—review the full policy against your previous version to identify specific differences.
Action Required
By September 24, 2025: (1) Billing and clinical teams must obtain prior authorization for all Margenza claims before submission—do not bill without approval. (2) Verify that patient meets ALL four criteria: metastatic breast cancer diagnosis, HER2 neu positive status (per ASCO-CAP guidelines), prior receipt of two anti-HER2 therapies (one in metastatic setting), and Margenza combined with approved chemotherapy (gemcitabine, eribulin, vinorelbine, or capecitabine). (3) Document HER2 status testing results (IHC 3+, IHC 2+ with ISH confirmation, or ISH results meeting specified thresholds) in the patient record before requesting authorization. (4) Update clinical staff workflows to screen for the exclusion: deny coverage requests if disease progression occurs on Margenza. (5) Ensure prior auth requests reference the September 24, 2025 revision date to confirm you are using current policy. Claims submitted without prior authorization or failing to meet all four criteria will be denied. Flag for your Medicaid compliance team: policy applies to Florida, Kentucky, South Carolina, and Virginia Medicaid plans.