Medicare AdvantagePrior AuthHigh impact
MA08.018j, Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Jun 16, 2025
We identified it
Jun 19, 2026
Summary
Medicare Advantage updated medical necessity criteria and medical coding requirements for Trastuzumab (Herceptin®) and related biosimilars, including Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta). This affects billing and prior authorization requirements for these cancer treatment medications.
Action Required
Before June 16, 2025: Billing team must review and update medical necessity documentation requirements for Trastuzumab (Herceptin) and biosimilar claims. Oncology providers should verify current prior authorization processes and ensure documentation meets new Medicare Advantage criteria. Update billing system alerts for these medications to prompt proper documentation collection.