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HumanaMedicare Advantage · Prior Auth · Medicaid · FL, KY, SC, VA · OncologyMedium impact

Margenza (margetuximab-cmkb) (Revised)

Act
immediately
Effective date
Not stated in the notice
Identified
Sep 22, 2026

Summary

This is a revised Humana prior authorization policy for Margenza (margetuximab-cmkb) effective for metastatic HER2-positive breast cancer treatment. The policy was updated on September 23, 2026 and applies to Medicare, Medicaid in Florida, Kentucky, South Carolina, and Virginia. Prior authorization is required for all Margenza claims and must meet four specific clinical criteria including prior anti-HER2 therapy and concurrent chemotherapy use.

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What to do

immediately · 6 steps
01Billing team must implement prior authorization requirement for Margenza (margetuximab-cmkb, HCPCS J9340) across all affected Humana plans (Medicare, Medicaid-FL, Medicaid-KY, Medicaid-SC, Medicaid-VA).
02Before claim submission, verify patient meets ALL four criteria: (1) metastatic breast cancer diagnosis, (2) HER2 neu positive (per ASCO-CAP 2018 guidelines), (3) two prior anti-HER2 therapies with one in metastatic setting, and (4) concurrent chemotherapy (gemcitabine, eribulin, vinorelbine, or capecitabine).
03Update billing software and encounter forms to capture these required clinical elements.
04Submit prior authorization requests through Humana's PAL system (www.humana.com/PAL) before dispensing.
05Flag for denial any claims lacking documentation of required criteria or showing disease progression on Margenza.
06Ensure state-specific Medicaid submissions include appropriate state modifier if required.

Codes mentioned

J9340

Original notice

Margenza (margetuximab-cmkb) (Revised)
mcp.humana.com · Always check the source before changing claims.
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Related changes

See all Humana changes →
Margenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Nov 1, 2025 · MedicaidMargenza (margetuximab-cmkb) (Revised)MediumEffective Sep 24, 2025 · MedicaidBrowse every Humana change in the policy list

Related policy hubs

Humana policiesFL policy changesKY policy changesSC policy changesVA policy changesOncologyCode J9340

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