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)
On February 20, 2020, the following language was added to the Company-Designated Preferred Products section of the Policy section: Coverage of a biosimilar product as an alternate to a reference product is not considered a form of step therapy by the Company.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
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 trastuzumab 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: 08.00.15f:Off-label Coverage for Prescription Drugs and/or Biologics
Policy: 08.01.07f:Pertuzumab (Perjeta®)
Policy: 08.01.11e:Ado-Trastuzumab Emtansine (Kadcyla®)