Medicare AdvantagePrior AuthMedium impact
Trodelvy (sacituzumab govitecan-hziy) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Trodelvy (sacituzumab govitecan-hziy) prior authorization policy effective November 26, 2025, covering Medicare and Medicaid (Florida, Kentucky, South Carolina). The policy maintains two distinct approval pathways: one for triple-negative breast cancer requiring ≥2 prior therapies (one metastatic), and one for HR-positive/HER2-negative breast cancer requiring endocrine therapy plus ≥2 additional systemic therapies in metastatic setting. Both pathways exclude members with prior disease progression on Trodelvy and require single-agent use.
Action Required
By November 26, 2025: Billing and authorization teams must update prior authorization workflows in all systems to reflect the revised Trodelvy policy. Verify that PA submission templates capture: (1) for triple-negative BC: confirmation of unresectable/metastatic disease AND documentation of ≥2 prior therapies with ≥1 in metastatic setting; (2) for HR+/HER2- BC: confirmation of endocrine therapy history AND ≥2 additional systemic therapies in metastatic setting. Add exclusion check to deny approval if member has experienced disease progression on Trodelvy. Train authorization staff on the distinction between the two indication pathways. Update provider communication materials to reflect November 26, 2025 revision date. Obtain authorizations for both indications before claims submission; claims submitted without appropriate prior auth will be denied. Note: This policy applies to Humana Medicare and Medicaid (FL, KY, SC) only—verify plan affiliation before applying these criteria.