Medicare AdvantagePrior AuthMedium impact
Herceptin Hylecta (trastuzumab and hyaluronidase oysk) (New)
Humana·Oncology·Medicare Advantage
Effective date
Sep 4, 2026
We identified it
Sep 4, 2026
Summary
Humana has implemented a new prior authorization policy for Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) effective September 4, 2026, for Medicare Advantage beneficiaries with HER2-positive breast cancer. The policy requires step therapy with preferred trastuzumab biosimilars (Trazimera or Ogivri for Part B; Trazimera or Kanjinti for Part D) before approval, unless patients have documented intolerance or contraindication. Prior authorization is required for all new requests and renewals.
Action Required
By September 4, 2026: (1) Billing and clinical teams must implement prior authorization requirement in billing system for all Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) requests under Humana Medicare Advantage plans. (2) Update authorization workflows to enforce step therapy: require documentation of intolerance or contraindication to preferred agents (Trazimera or Ogivri for Part B claims; Trazimera or Kanjinti for Part D claims) before Herceptin Hylecta approval is granted. (3) For continuation therapy within past 365 days, configure system to waive step therapy requirement and process automatically. (4) Reject claims with concurrent Kadcyla (ado-trastuzumab emtansine) or gastric/GEJ/esophageal carcinoma diagnoses. (5) Train providers and billing staff on the three approval criteria: HER2-positive breast cancer diagnosis, appropriate treatment indication (adjuvant with specific chemotherapy combinations or monotherapy; metastatic with specific first-line or post-chemo options), and step therapy compliance. (6) Ensure prior authorization is obtained before claims submission; claims submitted without required authorization will be denied.