MedicaidPrior AuthMedium impact
Faslodex (fulvestrant)
Humana·OH · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 6, 2026
Summary
Humana Ohio Medicaid implemented a new prior authorization policy for Faslodex (fulvestrant) effective November 1, 2025, for HR-positive, HER2-negative advanced breast cancer. The policy establishes specific approval criteria for monotherapy and combination therapy with CDK 4/6 inhibitors, requiring documentation of menopausal status, prior endocrine therapy history, and disease progression details.
Action Required
By November 1, 2025: Billing and clinical teams must implement prior authorization workflow for all Faslodex (fulvestrant) claims for Ohio Medicaid members. (1) Update billing system to flag all J9395 and J9396 claims for prior auth requirement before submission. (2) Create or update prior auth request templates to include required documentation: HR/HER2 receptor status, menopausal status or ovarian ablation/suppression confirmation, prior endocrine therapy history (e.g., anastrozole), and indication (monotherapy vs. combination with CDK 4/6 inhibitor). (3) For monotherapy claims: verify member is post-menopausal OR premenopausal with ovarian ablation/suppression, AND either treatment-naive to endocrine therapy OR experiencing disease progression/intolerance/contraindication. (4) For combination therapy claims: verify CDK 4/6 inhibitor partner (abemaciclib, palbociclib, or ribociclib) and disease type (advanced/metastatic, recurrent/unresectable). (5) Train providers and prior auth staff on new criteria. (6) Do NOT submit claims without prior authorization—non-compliant claims will be denied. Note: This policy applies only to Ohio Medicaid; verify member plan type before applying.