MedicaidPrior AuthHigh impact
Enhertu (fam-trastuzumab deruxtecan-nxki)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Jun 1, 2026
We identified it
Aug 8, 2026
Summary
Humana Medicaid Ohio has established a new prior authorization policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective June 1, 2026, covering seven oncologic indications including HER2-positive breast cancer, HER2-low/ultralow breast cancer, gastric adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors. All uses require prior authorization with specific clinical criteria including prior treatment history and contraindication of disease progression on Enhertu.
Action Required
By June 1, 2026: (1) Billing team must update billing system to require prior authorization for HCPCS code J9349 (Enhertu IV solution) for all Medicaid Ohio members. (2) Create prior authorization submission workflow requiring documentation of: diagnosis, HER2 status/mutation type, prior treatment history (including specific regimens per indication), and confirmation of monotherapy or combination therapy with pertuzumab. (3) Update provider templates and encounter forms with coverage criteria checklist for each of the seven indications. (4) Train clinical staff and providers on the seven distinct clinical pathways and their specific requirements (first-line vs. subsequent treatment, prior therapy requirements, HR-positive disease requirements for HER2-low/ultralow). (5) Implement system edits to flag and deny claims for members with documented disease progression on Enhertu. (6) Flag all prescriptions as requiring prior auth before dispensing. Failure to obtain prior authorization will result in claim denials. NOTE: Black box warnings for interstitial lung disease and embryo-fetal toxicity require patient counseling documentation.