MedicaidPrior AuthMedium impact
Datroway (datopotamab deruxtecan-dlnk)
Humana·LA · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 8, 2026
Summary
Humana Louisiana 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 as monotherapy only. Prior authorization is required for all requests.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirement for all Datroway (datopotamab deruxtecan-dlnk) claims submitted to Humana Louisiana Medicaid. Update billing system to flag claims for prior auth review before submission. Ensure providers document: (1) for breast cancer claims: HR-positive/HER2-negative diagnosis, prior endocrine-based therapy receipt, and at least one prior chemotherapy line in metastatic setting; (2) for NSCLC claims: EGFR mutation documentation (e.g., exon 19 deletion, L858R), prior EGFR-directed therapy (e.g., osimertinib), and prior platinum-based chemotherapy. Reject any claims where member has prior disease progression on Datroway. Route all requests through Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL for claim code verification. Claims submitted without prior authorization will be denied.