Medical Policy

Effective Date:01/01/2013 Title:Perjeta (Pertuzumab)
Revision Date:08/01/2023 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, salivary gland tumor, and colorectal 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:


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

Intentially left empty

1)    Perjeta Prescribing Information. South San Francisco, CA: Genentech, Inc.; February 2021. Available at Accessed January 5, 2023.

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

3)    National Comprehensive Cancer Network Guidelines. Breast Cancer Version 2.2023. Available at Accessed February 7, 2023.



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


Effective 08/01/2023: Updated all criteria.

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.