MedicaidPrior AuthMedium impact
Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Jan 1, 2023
We identified it
Sep 4, 2026
Summary
This is a revised Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) prior authorization policy for Medicaid in Florida, Kentucky, and South Carolina, effective January 1, 2023, with a revision date of September 4, 2026. The policy requires prior authorization for this subcutaneous HER2-positive breast cancer treatment and includes step therapy requirements (with an exception for Florida Medicaid). Key approval criteria include HER2-positive breast cancer diagnosis, specified treatment combinations or monotherapy regimens, and prior treatment/intolerance to Kanjinti or Trazimera, with exclusions for concurrent Kadcyla use and gastric/GEJ/esophageal carcinoma.
Action Required
Immediately implement the following for all Medicaid claims (FL, KY, SC) involving Herceptin Hylecta: (1) Billing team must establish prior authorization process in claims submission system requiring approval before claim processing; (2) For Kentucky and South Carolina Medicaid: Require documentation of prior intolerance or treatment with Kanjinti (trastuzumab-anns) or Trazimera (trastuzumab-qyyp) before authorizing Herceptin Hylecta—Florida Medicaid does not require this step therapy; (3) Verify all requests meet clinical criteria: HER2-positive breast cancer diagnosis AND approved treatment regimen (adjuvant or metastatic disease with specified chemotherapy combinations or monotherapy); (4) Deny or request additional documentation if member is using Kadcyla concomitantly or has gastric/GEJ/esophageal carcinoma diagnosis; (5) Update provider documentation templates and prior auth request forms to capture HER2 status, treatment intent (adjuvant vs. metastatic), specific chemotherapy regimen, and prior trastuzumab exposure; (6) Train billing and prior auth staff on state-specific differences, particularly Florida's exemption from step therapy requirements. Failure to obtain prior authorization will result in claim denials.