Medicare AdvantagePrior AuthHigh impact
Kadcyla (ado-trastuzumab emtansine) (Revised)
Humana·KY, SC · Oncology·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
This is a revised Kadcyla (ado-trastuzumab emtansine) prior authorization policy effective January 1, 2020, with the most recent revision dated November 26, 2025. The policy covers two indications: metastatic breast cancer (HER2-positive, post-trastuzumab and taxane therapy) and early breast cancer (HER2-positive with residual invasive disease post-neoadjuvant therapy). The billing team must ensure all Kadcyla claims include prior authorization before submission and verify HER2 status documentation, treatment history, and exclusion criteria are met.
Action Required
IMMEDIATE: Billing team must implement prior authorization requirement for all Kadcyla (ado-trastuzumab emtansine) intravenous solution claims submitted for Medicaid (Kentucky and South Carolina) and Medicare Advantage plans. Before submitting ANY Kadcyla claim, verify: (1) HER2-positive status documented (IHC 3+ or IHC 2+/ISH positive per 2018 ASCO-CAP guidelines); (2) for metastatic cases: prior trastuzumab and taxane therapy completed, with either prior metastatic treatment or recurrence within 6 months of adjuvant therapy; (3) for early breast cancer: neoadjuvant taxane and trastuzumab received with residual invasive disease, limited to 14 cycles maximum; (4) no concomitant trastuzumab, Tykerb (lapatinib), or Perjeta (pertuzumab); (5) no prior disease progression on Kadcyla. Update billing system authorization rules to require prior auth approval before claim submission. Add documentation checklist to encounter templates for oncology providers. Route all Kadcyla requests through prior authorization workflow. Claims submitted without prior auth approval will be denied. NOTE: Policy applies to Medicaid-Kentucky, Medicaid-South Carolina, and Medicare Advantage only; verify plan type before applying this policy.