CommercialCoverageMedium impact
08.00.12i, Fam-trastuzumab deruxtecan-nxki (Enhertu®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Apr 6, 2026
We identified it
Jun 19, 2026
Summary
The medical necessity criteria and billing codes for Fam-trastuzumab deruxtecan-nxki (Enhertu®) have been updated for commercial insurance plans. This affects pharmacy billing and coverage requirements for this cancer medication.
Action Required
By April 6, 2026: Billing team must review and update medical necessity criteria documentation requirements for Enhertu® (Fam-trastuzumab deruxtecan-nxki) prescriptions. Update billing system with any new coding requirements and ensure providers document appropriate medical necessity before prescribing. Review full policy at provided URL for specific criteria changes.