Medicare AdvantagePrior AuthMedium impact
Tukysa (tucatinib) (Revised)
Humana·Oncology, Hematology, Pharmacy·Medicare Advantage
Effective date
Oct 22, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has revised its Tukysa (tucatinib) prior authorization policy effective October 22, 2025. The policy covers two HER2-positive cancer indications: metastatic/advanced breast cancer (with prior anti-HER2 therapy) and RAS wild-type colorectal cancer (with prior multi-agent chemotherapy). Both require combination therapy with trastuzumab, and breast cancer requires capecitabine. Billing teams must ensure prior authorization is obtained before dispensing and verify member meets all clinical criteria.
Action Required
By October 22, 2025: Billing and pharmacy teams must implement prior authorization requirements for Tukysa (tucatinib) claims. (1) Update billing system to flag all Tukysa prescriptions as requiring prior auth before claims are submitted. (2) Create internal checklist to verify members meet ALL clinical criteria before requesting authorization: For breast cancer—metastatic/advanced HER2+ status, prior anti-HER2 regimen in metastatic setting, and concurrent trastuzumab + capecitabine use. For colorectal cancer—RAS wild-type HER2+ unresectable/metastatic status, prior fluoropyrimidine/oxaliplatin/irinotecan treatment, and concurrent trastuzumab use. (3) Deny or hold claims that show disease progression on Tukysa (exclusion criteria). (4) Pharmacy staff must verify trastuzumab product documentation in medical record. (5) Route all Tukysa requests through prior authorization portal at www.humana.com/PAL. Failure to obtain prior authorization will result in claim denials.