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Fam-trastuzumab Deruxtecan-nxki (Enhertu®)
BCBS Tennessee·Oncology, Pulmonology, Gastroenterology +2 more·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
This is a NEW medical policy for Fam-trastuzumab Deruxtecan-nxki (Enhertu®) covering multiple cancer indications including HER2-positive breast cancer, HER2-low/ultralow breast cancer, HER2-mutant NSCLC, gastric cancer, and other solid tumors. The policy establishes coverage criteria, prior authorization requirements, and documentation needs. CRITICAL: This policy is marked 'Do Not Implement until 9/30/26' — it is not yet active.
Action Required
By September 15, 2026 (2 weeks before effective date): Billing team and prior authorization staff must prepare systems and workflows. (1) Download and review the full policy document from the source URL. (2) In the billing system, create prior authorization rules requiring HER2 status documentation (IHC score or ISH test result) and hormone receptor status for ALL Enhertu claims. (3) Ensure prior auth submission templates capture: cancer type, HER2 status, hormone receptor status, disease stage/status (neoadjuvant, adjuvant, metastatic, recurrent), and prior treatment history. (4) Train billing staff and providers on the specific coverage criteria for each indication (breast cancer, NSCLC, gastric/GEJ, biliary tract, other solid tumors). (5) Notify oncology, radiation-oncology, and relevant surgical specialists of the new policy requirements. (6) Update encounter forms and order entry systems to prompt providers for required clinical documentation. (7) Flag all current or pending Enhertu prescriptions for review under new criteria before 9/30/26 to avoid claim denials. Failure to implement prior authorization requirements will result in claim denials for non-compliant submissions.