MedicaidPrior AuthHigh impact
Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Dec 17, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) prior authorization policy effective December 17, 2025. The policy clarifies coverage for HER2-positive breast cancer across three treatment scenarios: neoadjuvant therapy for locally advanced/inflammatory/early-stage disease, adjuvant therapy for early-stage disease at high recurrence risk, and first-line metastatic disease treatment. A critical 52-week/18-cycle lifetime treatment limit applies to both neoadjuvant and adjuvant therapy combined. All requests require prior authorization before dispensing.
Action Required
By December 17, 2025: Billing and clinical staff must implement the revised prior authorization requirements for all Phesgo claims. (1) Billing team: Update billing system to route all Phesgo requests through prior authorization process; flag any cumulative treatment approaching 52 weeks or 18 cycles across both neoadjuvant and adjuvant phases for medical director review. (2) Provider staff: Ensure all Phesgo requests include documentation of: HER2-positive status (per 2018 ASCO-CAP guidelines with specific IHC/ISH results), treatment phase (neoadjuvant, adjuvant, or metastatic), specific chemotherapy combination being used, and cumulative treatment duration to date. (3) Prior auth team: Verify member meets all applicable criteria for their cancer stage/treatment scenario; reject requests for experimental uses not supported by CMS-recognized compendia. (4) All staff: Be aware of black box warnings (cardiomyopathy, embryo-fetal toxicity, pulmonary toxicity) and ensure baseline cardiac function assessment is documented before approval. Claims submitted without prior authorization or exceeding the 52-week/18-cycle limit will be denied. This policy applies only to Medicaid members in FL, KY, and SC; verify member plan type before applying these requirements.