CommercialPrior AuthHigh impact
Fam-trastuzumab Deruxtecan-nxki (Enhertu) (CPB 0966, reviewed 2026-05-15)
Aetna·Oncology, Hematology·Medical Policy
Effective date
May 15, 2026
We identified it
Aug 15, 2026
Summary
Aetna has updated its medical policy for fam-trastuzumab deruxtecan-nxki (Enhertu) effective immediately, expanding coverage criteria across multiple cancer types including breast cancer (HER2-positive, HER2-low, HER2-ultralow, and HER2-negative), biliary tract cancer, esophageal/gastric adenocarcinoma, NSCLC, and solid tumors. All uses require precertification before treatment begins.
Action Required
Immediately: Billing and prior authorization teams must implement mandatory precertification process for all Enhertu (J9358) claims before treatment initiation. Update billing system to require precertification contact (866) 752-7021 or fax (888) 267-3277 for Aetna commercial plans. Providers must verify patient meets specific criteria: HER2 status (positive, low, ultralow, or negative for breast cancer), disease stage (recurrent, metastatic, unresectable, or residual disease), prior treatment history, and single-agent vs. combination therapy designation. Create decision tree in EMR or billing software to route claims based on cancer type and HER2 status. Rejected claims will be denied without prior authorization. Update encounter forms to require documentation of HER2 status, disease progression status, prior systemic treatments, and reason for Enhertu selection. Train oncology providers and front-desk staff on precertification requirements immediately.