Medical Policy

Effective Date:01/01/2013 Title:Perjeta (Pertuzumab)
Revision Date:10/01/2014 Document:BI388:00
CPT Code(s):C9292, J9306
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Perjeta requires prior authorization.

2)    Perjeta is used to treat breast cancer.

3)    Perjeta is an injectable product covered under the medical benefit as a specialty drug.

Medical Statement

Perjeta is considered medically necessary for patients who meet the following criteria:

 

1)     Diagnosis of metastatic HER2 positive breast cancer used in combination with trustuzumab (Herceptin) and docetaxel (Taxotere);  OR

2)    Diagnosis of early stage HER2 positive breast cancer and being used for neoadjuvant treatment  OR

3)    Diagnosis of early stage HER2 positive breast cancer and being used for adjuvant treatment:

a.    Patient has not received neoadjuvant therapy with pertuzumab-containing regimen AND

b.    Drug is being used in combination with trastuzumab (Herceptin) and a taxane (docetaxel or paclitaxel).

 

 

Codes Used In This BI:

 

C9292 Injection, pertuzumab, 10mg

J9306 Injection, pertuzumab, 10mg

Limits
Intentially left empty
Reference

1)    Perjeta Prescribing Information.  Genentech, Inc.  South San Francisco, CA  2012

2)    Clinical Pharmacology.  Accessed online November 26, 2012.

3)    Baselga J, Cortes J, Kim S, et al.  Pertuzumab plus Trastuzumab plus docetaxel for Metastic Breast Cancer.  N Engl J Med.  January 2012:355(2):109-19.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.