MedicaidPrior AuthMedium impact
Trastuzumab products (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2026
We identified it
Sep 2, 2026
Summary
Humana revised its Trastuzumab product prior authorization policy effective January 1, 2026, with updates implemented September 1, 2026. The policy now applies to seven trastuzumab biosimilars and the reference drug across Medicaid plans in Florida, Kentucky, and South Carolina for breast cancer and gastric cancer treatment. Key change: For non-Florida Medicaid members requesting branded trastuzumab products (Herceptin, Ogivri, Herzuma, Hercessi, Ontruzant), documented intolerance or contraindication to biosimilars Trazimera or Kanjinti is now required before approval; Florida Medicaid is exempt from this requirement.
Action Required
By January 1, 2026, the billing and prior authorization teams must: (1) Update the prior authorization system to require documentation of intolerance or contraindication to Trazimera (trastuzumab-qyyp) or Kanjinti (trastuzumab-anns) before approving requests for Herceptin, Ogivri, Herzuma, Hercessi, or Ontruzant for Medicaid members in Kentucky and South Carolina (does not apply to Florida Medicaid); (2) Ensure oncology providers document HER2 status (IHC 3+ or IHC 2+/ISH positive) using 2018 ASCO-CAP guidelines in clinical notes before submission; (3) For gastric cancer cases, verify that trastuzumab is prescribed with cisplatin AND either fluorouracil or capecitabine in the treatment plan; (4) Train billing staff to differentiate Florida Medicaid requests (which do NOT require intolerance documentation) from Kentucky and South Carolina Medicaid requests (which DO). Failure to obtain prior authorization or provide required documentation will result in claim denials.