Medicare AdvantageCoverageMedium impact
MA08.018m, Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Apr 20, 2026
We identified it
Jun 19, 2026
Summary
Medicare Advantage policy MA08.018m has been updated with new medical necessity criteria and medical coding requirements for Trastuzumab (Herceptin®) and related biosimilars, including Herceptin Hylecta. This affects billing and coverage determination for these cancer medications effective April 20, 2026.
Action Required
Before April 20, 2026: Billing team must review updated medical necessity criteria for Trastuzumab and biosimilar medications. Update prior authorization workflows and documentation requirements in billing system. Providers should ensure medical necessity documentation meets new criteria to avoid claim denials for Medicare Advantage patients receiving these cancer therapies.