Medicare AdvantagePrior AuthMedium impact
MA08.182b, Zanidatamab-hrii (Ziihera®)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Jun 29, 2026
We identified it
Jun 30, 2026
Summary
MA08.182b updates medical necessity criteria for Zanidatamab-hrii (Ziihera®), a newly approved oncology drug. This Medicare Advantage policy establishes new coverage requirements and approval conditions for this medication effective June 29, 2026. The billing team must implement prior authorization and medical necessity documentation requirements before this date.
Action Required
By June 29, 2026: Billing team must implement prior authorization requirement for HCPCS code J9271 (Zanidatamab-hrii injection) in the billing system. Obtain and review the full medical necessity criteria from the policy document at the provided URL. Update encounter documentation templates and provider communication to include requirements for prior auth submission. Coordinate with providers to ensure they document medical necessity according to the new criteria before dispensing. Establish workflow to submit prior auth requests before claims are submitted. Failure to obtain prior authorization will result in claim denials for Medicare Advantage beneficiaries.