ModifiedDelaware First HealthPolicy CP.PHAR.227

Pertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) coverage

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Defines medical necessity, prior authorization, and coverage criteria for pertuzumab (Perjeta) and its biosimilar pertuzumab-dpzb (Poherdy) for treatment of HER2-positive cancers for members of Delaware First Health across Commercial, HIM/ICHRA, and Medicaid lines of business.

Policy Summary

PayerDelaware First Health

PolicyPertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) coverage

Policy CodePolicy CP.PHAR.227

Change TypeAdded biosimilar (Poherdy)expanded regimens and duration limits

Effective DateJun 1, 2016

Next Review DateN/A

Key ActionSubmit prior authorization with diagnosis, oncologist involvement, age, indication, prior therapies, planned combination agents, and dosing (include J9306 on claims).

SourceLink

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ModifiedDelaware First HealthPolicy CP.PHAR.227

Pertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) coverage

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Sign up for Delaware First Health Policy CP.PHAR.227 alerts

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Policy Summary

PayerDelaware First Health

PolicyPertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) coverage

Policy CodePolicy CP.PHAR.227

Change TypeAdded biosimilar (Poherdy)expanded regimens and duration limits

Effective DateJun 1, 2016

Next Review DateN/A

Key ActionSubmit prior authorization with diagnosis, oncologist involvement, age, indication, prior therapies, planned combination agents, and dosing (include J9306 on claims).

SourceLink

POLICY UPDATE CHANGES

Added newly approved biosimilar, Poherdy, to the policy.

For breast cancer, added option for Perjeta without taxanes/chemotherapy for patients previously treated with chemotherapy and trastuzumab without pertuzumab; and added combinations with other agents (Enhertu) and aromatase inhibitor options in select patients.

For gallbladder cancer and cholangiocarcinoma, added option for treatment when resected gross residual (R2) disease is present; appended residual tumor (R) classification to Appendix D.

Continued therapy criteria updated to add maximum duration for neoadjuvant or adjuvant breast cancer not to exceed 1 year (up to 18 cycles) per prescribing information.

Initial approval durations for Medicaid and HIM extended from 6 to 12 months for all indications.