Pertuzumab (Perjeta®) is a monoclonal antibody that is a human epidermal growth factor receptor 2 (HER2) antagonists.
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.”
Pertuzumab (Perjeta) may be considered medically necessary for the treatment of breast cancer for ANY ONE of the following indications:
FDA Approved Indications:
NCCN Approved Indications:
The use of pertuzumab (Perjeta) is considered experimental/investigational and therefore non-covered for any other indications. Scientific evidence does not support the use for all other indications.
Note: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
* Note: Language derived from NCCN guidelines.