Currentblue cross blue shield - tennesseePolicy N/A

Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)

Defines coverage criteria, documentation requirements, authorization durations, continuation rules, and compendial/experimental determinations for Phesgo (subcutaneous pertuzumab + trastuzumab with hyaluronidase) when used for HER2-positive breast cancer in members of BlueCross BlueShield of Tennessee.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateID_CHS_2026

Next Review Date

Key ActionSubmission of HER2 status is necessary to initiate prior authorization review.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy content remains current with prior criteria.

3Covered Indications

1Compendial Use

1Experimental/Not Covered

Coverage Summary & Indications

Phesgo (subcutaneous fixed‑dose pertuzumab + trastuzumab with hyaluronidase) is covered with criteria aligned to FDA‑approved indications and recognized compendia for treatment of HER2‑positive breast cancer. Coverage includes neoadjuvant, adjuvant, and certain metastatic uses when all approval criteria are met and no exclusions apply.

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Covered Indications / Approval Criteria

The following FDA-approved indications and compendial uses are covered provided all approval criteria are met and the member has no exclusions to the prescribed therapy.

Covered Indications (ANY of)

Neoadjuvant treatment of breast cancer For use in combination with chemotherapy for the neoadjuvant treatment of adult patients with HER2-positive, locally advanced, inflammatory, or early-stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer.
Adjuvant treatment of breast cancer For use in combination with chemotherapy for the adjuvant treatment of adult patients with HER2-positive early breast cancer at high risk of recurrence.
Metastatic breast cancer (MBC) For use in combination with docetaxel for the treatment of adult patients with HER2-positive metastatic breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease.
Compendial use: May be substituted anywhere that the combination of intravenous pertuzumab and intravenous trastuzumab are given as part of systemic therapy for HER2-positive breast cancer.

Authorization Duration and Limits

Authorization may be granted subject to indication-specific duration rules.

ALL of the following

Authorization of 12 months may be granted for pre-operative (neoadjuvant) treatment of HER2-positive breast cancer in combination with chemotherapy for locally advanced, inflammatory, or early-stage breast cancer (either greater than 2 cm in diameter or node positive).
Authorization of 12 months may be granted for adjuvant treatment of HER2-positive breast cancer for locally advanced or early stage disease.
Authorization of 12 months may be granted for the treatment of HER2-positive recurrent unresectable or metastatic breast cancer or HER2-positive breast cancer with no response to preoperative systemic therapy.
Adjuvant and neoadjuvant treatments will be approved for a total of 12 months of therapy.

Continuation / Reauthorization

Continuation / Reauthorization Criteria

Conditions for continued therapy reauthorization.

ALL of the following

Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in the coverage criteria section when there is no evidence of unacceptable toxicity or disease progression while on the current regimen.
Adjuvant and neoadjuvant treatment of breast cancer will be approved for a total of 12 months of therapy.

Provider Actions & Prior Authorization

Prior Authorization

Prior authorization required

Prior authorization is required for Phesgo. Authorizations are typically granted for up to 12 months depending on the indication (neoadjuvant, adjuvant, or metastatic uses as specified in the policy). Reauthorization (continuation of therapy) may be approved for another 12 months only when there is no evidence of unacceptable toxicity and no disease progression while on the current regimen.

PA required
Typical authorization duration: up to 12 months
Reauthorization contingent on no unacceptable toxicity or disease progression

Documentation Required

HER2 status required

Submission of HER2 status is required to initiate the prior authorization review for Phesgo. Documentation of human epidermal growth factor receptor 2 (HER2) status must be provided with the request.

Provide HER2 test results when submitting PA

Background & Scope

Background and scope: Phesgo is the subcutaneous fixed‑dose combination of pertuzumab and trastuzumab with hyaluronidase for treatment of HER2‑positive breast cancer. The policy follows FDA indications and compendial guidance (e.g., NCCN, Micromedex, AHFS) for dosing, contraindications, and monitoring. The policy defines coverage criteria, documentation requirements (including submission of HER2 status), authorization durations (typically up to 12 months for neoadjuvant, adjuvant, and certain metastatic or recurrent indications), continuation/reauthorization rules, and states that uses outside the listed indications are considered experimental/investigational for BlueCross BlueShield of Tennessee members.

Revision History

ID_CHS_2026policy_effectiveLatest

Policy effective date identifier provided (ID_CHS_2026). No dated revision history entries were provided in the brief; policy follows FDA indications and compendia for Phesgo and requires submission of HER2 status for prior authorization. Authorization durations (typically up to 12 months) and continuation criteria are specified; additional dosing, contraindication, and monitoring details are referenced to standard compendia.