This version of the policy will become effective 05/15/2020.
This policy has been updated to communicate the Company's designation of two biosimilars as its preferred products: trastuzumab-qyyp (TrazimeraTM) and trastuzumab-anns (KanjintiTM).
Use of the non-preferred products trastuzumab (Herceptin®) or any non-preferred biosimilar is considered medically necessary and, therefore, covered only for individuals who are currently receiving or have previously received a non-preferred product for the specified trastuzumab indication.
If the individual has not previously received trastuzumab (Herceptin®) or a bevacizumab biosimilar to treat the specified indication, these non-preferred products are eligible for coverage when the individual has contraindication(s) or intolerance(s) to the Company designated preferred products (e.g., as documented per the FDA labeling).
TRASTUZUMAB AND RELATED BIOSIMILARS
Trastuzumab and related biosimilars are considered medically necessary and, therefore, covered for the following indications and regimens when the above requirements of HER2 PROTEIN OVEREXPRESSION TESTING, COMPANY-DESIGNATED PREFERRED PRODUCTS, and NON-PREFERRED PRODUCTS sections are met:
J9356 Injection, trastuzumab, 10 mg and Hyaluronidase-oysk
Q5112 Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg
Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg
Q5114 Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg
Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg
Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg
Policy: MA08.063c:Pertuzumab (Perjeta®)
Policy: MA08.066c:Ado-Trastuzumab Emtansine (Kadcyla®)