MedicaidPrior AuthMedium impact
Datroway (datopotamab deruxtecan-dlnk)
Humana·IN · Oncology·Medicaid
Effective date
Nov 1, 2025
We identified it
Aug 8, 2026
Summary
Humana Indiana Medicaid has established a new prior authorization policy for Datroway (datopotamab deruxtecan-dlnk), effective November 1, 2025. The policy covers two indications: HR-positive/HER2-negative breast cancer (requiring prior endocrine therapy and at least one line of chemotherapy) and EGFR-mutated NSCLC (requiring prior EGFR-directed therapy and platinum-based chemotherapy). Both indications require prior authorization and exclude members with prior disease progression on Datroway.
Action Required
By November 1, 2025: Billing team must implement prior authorization requirement for all Datroway (datopotamab deruxtecan-dlnk) claims submitted under Indiana Medicaid. (1) Update billing system and EMR to flag Datroway infusions for prior auth submission before claims are billed. (2) Create prior auth checklist requiring: documented diagnosis (unresectable/metastatic HR+/HER2- breast cancer OR locally advanced/metastatic EGFR-mutated NSCLC), evidence of prior therapy per indication (endocrine + chemotherapy for breast cancer; EGFR-directed + platinum-based for NSCLC), and confirmation monotherapy/appropriate regimen. (3) Train billing and clinical staff to deny or hold claims if prior auth documentation shows disease progression on prior Datroway. (4) Refer providers to Humana PAL portal (www.humana.com/PAL) for medical coding and prior auth submission instructions. (5) Document all prior auth decisions in patient record. Failure to obtain prior authorization will result in claim denials for Indiana Medicaid members.