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

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

Effective date
Nov 1, 2026
Identified
Nov 1, 2026

Summary

Humana Medicaid Indiana has established a new pharmacy coverage policy for Enhertu (fam-trastuzumab deruxtecan-nxki) effective November 1, 2026, covering seven HER2-related cancer indications including early breast cancer, metastatic breast cancer, HER2-low and HER2-ultralow breast cancer, gastric adenocarcinoma, HER2-mutant NSCLC, and HER2-positive solid tumors. All uses require prior authorization with specific clinical criteria and treatment cycle limits.

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What to do

Action · 3 steps
01As of November 1, 2026: Billing and prior authorization teams must implement prior authorization requirements for all Enhertu (fam-trastuzumab deruxtecan-nxki) claims submitted to Humana Medicaid Indiana.
02Update prior auth templates and billing system workflows to capture: (1) cancer diagnosis type and HER2 status (positive, low, ultralow, or mutant); (2) treatment setting (neoadjuvant vs. adjuvant for breast cancer, or applicable scenario for other indications); (3) prior treatment history and regimen details; (4) planned treatment cycle count (maximum 4 cycles for neoadjuvant early breast cancer, 14 cycles for adjuvant early breast cancer, or plan year duration for other indications); and (5) confirmation that monotherapy or specified combination therapy (pertuzumab for first-line metastatic HER2-positive breast cancer) is being used.
03Verify with providers that treatment does not exceed specified cycle limits before submitting authorization requests, as exceeding these limits is an explicit exclusion criterion that may result in denial.

Original notice

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

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Enhertu (fam-trastuzumab deruxtecan-nxki) (New)HighEffective Nov 1, 2026 · MedicaidEnhertu (fam-trastuzumab deruxtecan-nxki) (New)MediumEffective Jun 1, 2026 · MedicaidEnhertu (fam-trastuzumab deruxtecan-nxki) (New)MediumEffective Jun 1, 2026 · MedicaidEnhertu (fam-trastuzumab deruxtecan-nxki) (New)MediumEffective Jun 1, 2026 · MedicaidBrowse every Humana change in the policy list

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