MedicaidPrior AuthHigh impact
Faslodex (fulvestrant)
Humana·IN · Oncology, Pharmacy·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 6, 2026
Summary
Humana Indiana Medicaid has implemented a new prior authorization policy for Faslodex (fulvestrant) effective November 1, 2025. The policy requires prior authorization for all fulvestrant use in breast cancer treatment, with specific clinical criteria for monotherapy versus combination therapy with CDK 4/6 inhibitors. Billing teams must identify all fulvestrant claims and obtain pre-approval before dispensing to avoid claim denials.
Action Required
By November 1, 2025: (1) Billing and pharmacy teams must implement prior authorization requirement for all Faslodex/fulvestrant intramuscular syringe claims for Indiana Medicaid members before dispensing. (2) Update billing system and pharmacy management software to require PA submission for HCPCS code J9395. (3) Create or update PA request templates to capture required clinical criteria: HR+/HER2- status, menopausal status, prior endocrine therapy history, and therapy type (monotherapy vs. combination with CDK 4/6 inhibitor). (4) Train pharmacy staff to verify member meets all applicable criteria (Criteria #1, #2, and #3 for monotherapy OR Criteria #1 and #2 for combination therapy) before submitting PA. (5) Establish process to document member's menopausal status and ovarian ablation/suppression therapy if premenopausal. Claims submitted without prior authorization will be denied by Humana Indiana Medicaid.