Medicare AdvantagePrior AuthMedium impact
MA08.114h, Fam-trastuzumab deruxtecan-nxki (Enhertu®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Jun 16, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage has updated medical necessity criteria for fam-trastuzumab deruxtecan-nxki (Enhertu®), a targeted cancer therapy drug. This affects prior authorization requirements and coverage criteria for this specialty oncology medication.
Action Required
By June 16, 2025: Oncology billing team must review updated medical necessity criteria for Enhertu® (fam-trastuzumab deruxtecan-nxki) prior authorizations. Update prior auth workflows to ensure compliance with new Medicare Advantage criteria. Coordinate with providers to verify documentation meets updated requirements before submitting claims.