Trastuzumab biosimilar products (Kanjinti, Ogrivi, Herzuma, Ontruzant, and
Trazimera) and Herceptin Hylecta are covered without PA. They are subject to
retrospective review to ensure they are used in compliance with the Medical
Policy Statement below.
Herceptin requires prior authorization (PA). For new patients, a
biosimilar product or Herceptin Hylecta must be tried first before Herceptin
would be approved.
Trastuzumab is considered medically necessary for patients meeting the following
criteria and subject to the step therapy noted immediately above.
Breast Cancer
1)
Diagnosis of
HER2-positive breast cancer AND
2)
Age >18 years old
AND
Gastric, Esophageal and
Esophagogastric Junction Cancer
1)
Diagnosis of
HER2-positive metastatic gastric, esophageal, orEGJ adenocarcinoma AND
2)
Age >18 years old
AND
3)
Prescribed in combination
with cisplatin and either capecitabine or 5-fluorouracil
Endometrial Carcinoma
1)
Diagnosis of
HER2-positive endometrial carcinoma with serous histology AND
2)
Age >18 years old
AND
3)
Disease is advanced (i.e.
stage III/IV) or recurrent AND
4)
Prescribed in combination
with carboplatin and paclitaxel
Reauthorization is allowed if patient is responding to therapy and above
prescribing guidelines are met for the specific diagnosis.
Codes
Used In This BI:
Q5112 – Injection, trastuzumab-dttb, biosimilar (Ontruzant), 10mg
Q5113 – Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10mg
Q5114 – Injection, trastuzumab-dkst, biosimilar, (Ogivri), 10mg
Q5116 – Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10mg
Q5117 – Injection, trastuzumab-anns, biosimilar, (kanjinti), 10mg
J9355 – Injection, trastuzumab, excludes biosimilar, 10mg
J9356 – Injection, trastuzumab, 10mg and Hyaluronidase-oysk