Medicare AdvantageCoverageHigh impact
MA08.018l, Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Jan 1, 2026
We identified it
Jun 19, 2026
Summary
This policy establishes coverage and reimbursement guidelines for trastuzumab (Herceptin®), its biosimilars, and trastuzumab with hyaluronidase-oysk (Herceptin Hylecta) effective January 1, 2026. The billing team must review specific coverage criteria, prior authorization requirements, and reimbursement positions to ensure compliant claim submission for this cancer therapy.
Action Required
By December 31, 2025: Billing team must obtain and review the full MA08.018l policy text at the provided URL to identify: (1) specific HCPCS/CPT codes for trastuzumab products covered, (2) prior authorization requirements and submission processes, (3) reimbursement rates and allowed amounts, and (4) medical necessity documentation requirements. Update billing software rules, claim submission workflows, and prior auth templates accordingly. Oncology providers must be notified of any new documentation or coding requirements. Failure to comply with coverage and prior auth requirements will result in claim denials. Contact your Medicare Advantage plan representatives if specific codes or requirements are not clearly stated in the policy.