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HumanaMedicaid · Prior Auth · Medicaid · IN · Oncology, Hematology, PulmonologyHigh impact

Enhertu (fam-trastuzumab deruxtecan-nxki)

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

Summary

Humana Indiana Medicaid has established a new prior authorization policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective June 1, 2026, covering seven oncologic indications including HER2-positive, HER2-low, and HER2-ultralow breast cancers, gastric/GEJ adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors. All uses require prior authorization with specific clinical criteria that must be met for approval, including prior treatment requirements and monotherapy or combination restrictions.

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What to do

by Jun 1, 2026 · 6 steps
01Billing team must implement prior authorization requirements in billing software for Enhertu (J9349) for all Humana Indiana Medicaid members.
02Providers must submit prior auth requests documenting: (1) specific cancer diagnosis and HER2 status (positive/low/ultralow with IHC/ISH values), (2) prior treatment history (chemotherapy, anti-HER2 regimens, endocrine therapy), and (3) whether drug will be used as monotherapy or in combination with pertuzumab.
03Front desk and clinical staff must update encounter forms to capture HER2 classification (IHC 3+, IHC 2+/ISH-, IHC 1+, IHC 0) and prior therapy details.
04Update denial management protocols to flag claims lacking prior authorization as automatic denials.
05Flag for monitoring: claims will be denied if member has documented disease progression on Enhertu.
06Training required for billing, clinical, and prior auth teams on the seven distinct indication pathways and their differing requirements.

Codes mentioned

J9349

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 policiesIN policy changesOncologyHematologyPulmonologyCode J9349

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