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Fam-trastuzumab Deruxtecan-nxki (Enhertu®)
BCBS Tennessee·Oncology, Hematology·Medical Policy
Effective date
Jun 30, 2026
We identified it
Jun 17, 2026
Summary
New medical policy for Enhertu (fam-trastuzumab deruxtecan-nxki) establishes prior authorization requirements and coverage criteria for multiple cancer types including breast cancer, lung cancer, gastric cancer, and various HER2-positive solid tumors. The policy requires specific documentation of HER2 status and hormone receptor status for coverage approval.
Action Required
By June 30, 2026: Billing team must implement prior authorization workflows for Enhertu (fam-trastuzumab deruxtecan-nxki). Update systems to require HER2 status documentation (IHC score, ISH test results) and hormone receptor status before submitting claims. Train staff on new coverage criteria for breast cancer, lung cancer, gastric cancer, and solid tumor indications. Claims without proper prior authorization and documentation will be denied.