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HumanaMedicaid · Prior Auth · Medicaid · LA · Oncology, HematologyHigh impact

Enhertu (fam-trastuzumab deruxtecan-nxki) (New)

Act
by Nov 1, 2026
Effective date
Nov 1, 2026
Identified
Nov 1, 2026

Summary

Humana Louisiana Medicaid has established a new prior authorization pharmacy coverage policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective November 1, 2026. The policy covers seven HER2-related cancer indications with specific clinical criteria for approval, including early breast cancer, metastatic breast cancer, HER2-low/ultralow breast cancer, gastric adenocarcinoma, HER2-mutant non-small cell lung cancer, and HER2-positive solid tumors. Billing teams must implement prior authorization requirements for all Enhertu claims under Louisiana Medicaid before the effective date.

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What to do

by Nov 1, 2026 · 5 steps
01Billing team must implement prior authorization requirements in the billing system for Enhertu (J9349) for Louisiana Medicaid members.
02Specific authorization criteria vary by indication: HER2-positive early breast cancer (neoadjuvant limited to 4 cycles; adjuvant limited to 14 cycles), HER2-positive unresectable/metastatic breast cancer (first-line with pertuzumab or monotherapy after prior anti-HER2 therapy), HER2-low/ultralow metastatic breast cancer (after prior chemotherapy or endocrine therapy failure), gastric/gastroesophageal junction adenocarcinoma (after trastuzumab), HER2-mutant NSCLC (after prior systemic therapy), and HER2-positive solid tumors (after prior systemic treatment).
03Prior authorization approval duration is through plan year or as determined by clinical review.
04Denial should occur if member exceeds specified treatment cycles or experiences disease progression on Enhertu.
05Confirm current policy version at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a60cac5 before submitting claims, as Humana updates policies regularly online.

Codes mentioned

J9349

Original notice

Enhertu (fam-trastuzumab deruxtecan-nxki) (New)
mcp.humana.com · Always check the source before changing claims.
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Related policy hubs

Humana policiesLA policy changesOncologyHematologyCode J9349

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