Medicare AdvantagePrior AuthHigh impact
Trastuzumab products (New)
Humana·Oncology, Hematology·Medicare Advantage
Effective date
Sep 1, 2026
We identified it
Sep 2, 2026
Summary
Humana has implemented a new prior authorization policy for trastuzumab products (7 biosimilar and brand-name formulations) effective September 1, 2026, covering breast cancer, gastric cancer, and other medically accepted uses. The policy establishes preferred products by Medicare coverage type (Part B prefers Trazimera/Ogivri; Part D prefers Trazimera/Kanjinti) and requires prior auth for non-preferred products unless the member has documented intolerance/contraindication, with no step therapy requirement for continuation therapy within 365 days.
Action Required
By August 31, 2026: Billing and prior authorization teams must implement this new prior auth requirement in billing systems and workflow. (1) Update the prior authorization submission process to require clinical documentation of HER2 status (IHC 3+ or IHC 2+/ISH positive) for all trastuzumab requests. (2) For Medicare Part B requests, program system to designate Trazimera and Ogivri as preferred; require documentation of intolerance/contraindication for non-preferred products (Herceptin, Kanjinti, Ontruzant, Herzuma, Hercessi). (3) For Medicare Part D requests, program system to designate Trazimera and Kanjinti as preferred; require documentation of intolerance/contraindication for non-preferred products. (4) Configure system to exempt continuation therapy requests (same drug within past 365 days) from step therapy for Medicare Part B. (5) For gastric cancer claims, verify that trastuzumab is combined with cisplatin plus fluorouracil or capecitabine before approval. (6) Notify providers and update prior authorization forms/instructions to identify the 7 affected trastuzumab products and new preferred product hierarchy. (7) Train billing staff on new approval duration rules (initial and renewal approvals at plan year duration or per clinical review). Without prior authorization obtained before claim submission, Medicare Advantage claims will be denied.