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HumanaMedicaid · Prior Auth · Medicaid · LA · Oncology, HematologyHigh impact

Enhertu (fam-trastuzumab deruxtecan-nxki)

Act
by Jun 1, 2026
Effective date
Jun 1, 2026
Identified
Aug 8, 2026

Summary

Humana Louisiana Medicaid has released a new prior authorization policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective June 1, 2026, covering six oncology indications including HER2-positive/low/ultralow breast cancer, gastric adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors. The policy establishes specific clinical criteria for approval and requires prior authorization before dispensing, with disease progression on Enhertu as an automatic exclusion for renewal.

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What to do

by Jun 1, 2026 · 5 steps
01Billing team must configure pharmacy billing system to require prior authorization for Enhertu (HCPCS J9271) for all Louisiana Medicaid members before claims are submitted.
02Update prior authorization requirements in EMR/billing software to enforce the six indication-specific clinical criteria outlined in policy (HER2-positive breast cancer, HER2-low breast cancer, HER2-ultralow breast cancer, gastric/GEJ adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors).
03Pharmacy staff must verify patient meets all applicable criteria per indication before dispensing.
04Oncology providers and pharmacy team must ensure prior auth requests include proof of prior treatment/disease progression as specified for each indication.
05Flag and deny any renewal claims for patients with documented disease progression on Enhertu per Exclusion #1.
If missed: Failure to obtain prior authorization will result in claim denials on all Enhertu infusions for Louisiana Medicaid members.

Codes mentioned

J9271

Original notice

Enhertu (fam-trastuzumab deruxtecan-nxki)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesLA policy changesOncologyHematologyCode J9271

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