CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form

Form and authorization requirements for outpatient medical-benefit requests of trastuzumab (Herceptin) and listed biosimilars for Highmark Blue Shield of Northeastern New York members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Herceptin (Trastuzumab) Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form with clinical documentation to Highmark at 1-833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1fax number to submit form

6non-preferred product entries listed

Medicare, Commercialmember types noted

Medical Onlybenefit channel

Coverage Criteria

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Chemotherapy Herceptin (Trastuzumab) Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionFax the completed Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form with clinical documentation to Highmark at 1-833-619-5745.

SourceLink

On This Page

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Non-preferred coverage conditions: Member must have documented therapy failure after an adequate therapeutic trial of a preferred product OR the preferred product was not tolerated OR the preferred product is contraindicated; Medicare members already established on a non-preferred therapy are exempt from the trial requirement.

Operational: provider must document the rationale on the request form and attach supporting clinical records (progress notes, testing) before non-preferred coverage will be considered.

No additional formal exclusions are listed in this policy beyond the stated preference and step-therapy requirements. Providers should be aware that selection of a non-preferred product without required documentation—specifically evidence of documented therapy failure of a preferred product, intolerance, or contraindication—may result in denial of coverage. The form instructs providers to fax the completed request and supporting records to Highmark at 1-833-619-5745 when requesting authorization for trastuzumab or a listed biosimilar.

Products and Codes Listed on Form

Products listed on formHCPCS

J9355	Herceptin (listed on form)
Q5117	Kanjinti (biosimilar) listed as non-preferred
Q5116	Trazimera (biosimilar) listed as non-preferred
Q5112	Ontruzant (biosimilar) listed as non-preferred
Q5114	Ogivri (biosimilar) listed as non-preferred
Q5113	Herzuma (biosimilar) listed as non-preferred

Prior authorization via form - HCPCS codesHCPCS

J9355	Herceptin (listed on form)
Q5112	Ontruzant (biosimilar) listed as non-preferred
Q5113	Herzuma (biosimilar) listed as non-preferred
Q5114	Ogivri (biosimilar) listed as non-preferred
Q5116	Trazimera (biosimilar) listed as non-preferred
Q5117	Kanjinti (biosimilar) listed as non-preferred

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient chemotherapy trastuzumab (Herceptin) and biosimilars. Use the Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form and fax completed form to 1-833-619-5745 (medical benefit claims).

Form title: Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form
Fax: 1-833-619-5745
Include: Member name, DOB, UMI, payer type (Medicare/Commercial), requesting physician name and NPI, facility name and NPI, date of service, J-code(s), diagnosis code(s)

Denial Risk

Non-preferred Product Selection Risk

Selection of a non-preferred trastuzumab product (listed biosimilars and Herceptin J9355) carries a requirement to document prior therapeutic trial or medical rationale. Medicare members already established on a non-preferred therapy are exempt from the trial requirement.

Non-preferred products: Kanjinti (Q5117), Trazimera (Q5116), Ontruzant (Q5112), Ogivri (Q5114), Herzuma (Q5113), Herceptin (J9355)
Non-preferred use allowed when member has documented failure of a preferred product, preferred product not tolerated, or contraindicated
Medicare members currently established on a non-preferred therapy do not need to trial a preferred product

Documentation Required

Required Submission Details and Attachments

Submit the completed request form with required clinical details and attachments. Incomplete submissions or missing documentation may delay or result in denial of authorization.

Clinical questions on form must be answered (cancer type/histology and stage, complete chemotherapy regimen, line of therapy, prior therapies with progression/relapse details, ECOG score, resectability status)
Attach pertinent clinical information (progress notes, genetic testing, prior treatment records)
Indicate if a non-preferred product was selected and provide rationale for selection over a preferred product

Note

Provider Action: Form Submission and Eligibility Verification

Verify member eligibility and benefits before submission. Fax the completed form to Highmark Blue Shield of Northeastern New York at 1-833-619-5745.

Verify eligibility & benefits with the health plan prior to requesting authorization
Fax completed form to Highmark: 1-833-619-5745

Background

Trastuzumab (Herceptin) and listed biosimilars are managed under the outpatient medical benefit and require prior authorization via the Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form. The form is intended to document clinical details necessary to determine medical necessity for HER2-directed therapy, including cancer histology and stage, the full chemotherapy regimen, line of therapy, prior therapies and response, ECOG performance status, disease resectability, and any rationale for selecting a non-preferred product. Providers must attach pertinent clinical records (for example, progress notes and genetic testing) to support the request.

Definitions

Non-preferred product definition

DefinitionA non-preferred product is any trastuzumab product listed on the form under 'NON-PREFFERED' (Kanjinti Q5117; Herceptin J9355; Trazimera Q5116; Ontruzant Q5112; Ogivri Q5114; Herzuma Q5113).

Consideration criteriaA non-preferred product will be considered only when the member has documented therapy failure after an adequate trial of a preferred product, OR the preferred product is not tolerated OR is contraindicated.

Medicare exceptionMedicare members currently established on a non-preferred therapy are not required to try a preferred option (exempt from the trial requirement).

Operational requirementIf a non-preferred product is selected, the provider must document the rationale for selection on the form and attach supporting clinical records (progress notes, genetic testing, etc.).

Submission instructionFax the completed form (with rationale and attachments) to Highmark at 1-833-619-5745.

Step	Requirement	Exceptions / Notes
1	Trial of a preferred product is required and member must have documented therapy failure after an adequate therapeutic trial of a preferred product before a non-preferred product will be considered.	Medicare members already established on a non-preferred therapy are exempt from the trial requirement. Provider must document rationale on the form and attach supporting clinical records.

Biosimilar Products (listed as non-preferred)

Billing Rule

Herceptin (J9355) listed as non-preferred

Herceptin (J9355) is listed among the non-preferred products on the form and is subject to the policy's non-preferred coverage conditions.

Documentation Required

Documentation required when selecting Herceptin as non-preferred

If Herceptin (J9355) is selected as a non-preferred product, provide documentation of prior preferred-product trial failure, intolerance, or contraindication on the form; Medicare members already on non-preferred therapy are exempt from the trial requirement.

Include explicit rationale on the form when selecting Herceptin over preferred options

Billing Rule

Include J9355 in J-code field and supporting records

List Herceptin (J9355) as the J-code on the form (J-code(s) field) and attach supporting clinical records to justify non-preferred selection if applicable.

Prior Authorization

Fax submission required for Herceptin prior authorization

Failure to fax the completed form and attachments to the provided number (1-833-619-5745) may prevent prior authorization processing for Herceptin (J9355) under the medical benefit.

Documentation Required

Provide clinical details on form to support Herceptin (J9355) request

When requesting Herceptin (J9355) as a non-preferred product, answer the form's clinical questions about cancer histology and stage, full chemotherapy regimen, line of therapy, prior therapies (including progression or relapse), ECOG score, and disease resectability to support medical necessity determinations.

OpenPayer

Outpatient Chemotherapy Herceptin (Trastuzumab) Request Form

Coverage Criteria

Products and Codes Listed on Form

Provider Actions and Prior Authorization

Background

Definitions

Step Therapy Requirements

Site of Care

Biosimilar Products (listed as non-preferred)