MedicaidPrior AuthHigh impact
Datroway (datopotamab deruxtecan-dlnk)
Humana·OH · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 8, 2026
Summary
Humana Ohio Medicaid has established a new prior authorization policy for Datroway (datopotamab deruxtecan-dlnk), effective November 1, 2025. Coverage is limited to two indications: HR-positive/HER2-negative metastatic breast cancer (after prior endocrine therapy and chemotherapy) and EGFR-mutated NSCLC (after prior EGFR-directed therapy and platinum-based chemotherapy), both requiring prior authorization and monotherapy use for breast cancer.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirement for Datroway (J9311) for all Ohio Medicaid members. Update billing system to flag all Datroway claims for manual prior authorization review before submission. Providers must verify patient meets ALL criteria before prescribing: (1) confirmed diagnosis with appropriate biomarker status (HR+/HER2- breast cancer OR EGFR-mutated NSCLC), (2) documented prior therapy lines as specified, (3) monotherapy only for breast cancer indication. Front desk and clinical staff must obtain prior authorization documentation before dispensing. Verify member has not experienced prior disease progression on Datroway. Claims submitted without prior authorization will be denied. Maintain copies of prior authorization approvals with claim submissions. Implement workflow to track approval duration (initial and renewal plan year limits apply).