CommercialPrior AuthMedium impact
08.00.12h, Fam-trastuzumab deruxtecan-nxki (Enhertu®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Jun 16, 2025
We identified it
Jun 19, 2026
Summary
Medical necessity criteria have been updated for Fam-trastuzumab deruxtecan-nxki (Enhertu®), a specialty oncology medication. This policy change affects prior authorization requirements and coverage criteria for commercial insurance plans.
Action Required
By June 16, 2025: Billing team must review updated medical necessity criteria for Enhertu® (Fam-trastuzumab deruxtecan-nxki) prior authorizations. Update prior authorization checklists and ensure providers document compliance with new medical necessity requirements. Claims may be denied if updated criteria are not met.