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, salivary gland tumor, and colorectal cancer.

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

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

A.   Breast Cancer (must meet all):

1.    Diagnosis of HER2-positive breast cancer;

2.    Prescribed by or in consultation with an oncologist;

3.    Age > 18 years;

4.    Prescribed in combination with trastuzumab and one of the following: (a, b, or c):

a.    With taxane=containing chemotherapy (e.g. docetaxel or paclitaxel) for the treatment of metastatic breast cancer;

b.    With chemotherapy as neoadjuvant or adjuvant treatment;

c.    Member was previously treated with chemotherapy and trastuzumab in absence of Perjeta;

B.   Additional NCCN Recommended Uses (off-label) (must meet all):
1. Diagnosis of one of the following:

a.            Recurrent HER2-positive salivary gland tumor;

b.            Unresectable or metastatic HER2-positive gall bladder cancer or cholangiocarcinoma;

c.        Advanced or metastatic colorectal cancer and disease is all of the following:

1.    HER2 positive;

2.    Wild-type RAS (defined as wild-type in both KRAS and NRAS as determined by an FDA-approved test for this use);

3.    Wild-type BRAF

2.    Prescribed by or in consultation with an oncologist;

3.    Age > 18 years;

4.    Prescribed in combination with trastuzumab;

Codes Used In This BI:

C9292 Injection, pertuzumab, 1mg

J9306 Injection, pertuzumab, 1mg

1)    Perjeta Prescribing Information. South San Francisco, CA: Genentech, Inc.; February 2021. Available at https://www.gene.com/download/pdf/perjeta_prescribing.pdf. Accessed January 5, 2023.

2)    National Comprehensive Cancer Network Drugs and Biologics Compendium. Available at www.nccn.org. Accessed February 6, 2023.

3)    National Comprehensive Cancer Network Guidelines. Breast Cancer Version 2.2023. Available at https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed February 7, 2023.

Addendum:

Effective 12/01/2021: Added coverage criteria for salivary gland tumor and colorectal cancer.

Effective 08/01/2023: Updated all criteria.