Medicare AdvantageCoverageMedium impact
MA08.114i, Fam-trastuzumab deruxtecan-nxki (Enhertu®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Apr 6, 2026
We identified it
Jun 19, 2026
Summary
Medicare Advantage updated medical necessity criteria and medical coding requirements for fam-trastuzumab deruxtecan-nxki (Enhertu®), a specialty oncology drug. This affects billing and coverage determination for this targeted cancer therapy.
Action Required
Before April 6, 2026: Oncology billing team must review updated medical necessity criteria for Enhertu® (fam-trastuzumab deruxtecan-nxki) in Medicare Advantage plans. Update prior authorization workflows and ensure documentation meets new medical necessity requirements. Verify correct coding procedures for this specialty oncology drug to prevent claim denials.