BlueCross BlueShield of Tennessee Medical Policy Manual
Trastuzumab Products (Herceptin®, Ontruzant®, Herzuma®, Ogivri®, Trazimera™, Kanjinti™, Hercessi™)
Some agents on this policy may require step therapy See “Step Therapy Requirements for Provider Administered Specialty Medications” Document at: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the medical policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
POLICY
INDICATIONS
The indications below including FDA-approved indications and compendial uses are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.
FDA-Approved Indications
Adjuvant breast cancer
Adjuvant treatment of human epidermal growth factor receptor 2 (HER2)-overexpressing node positive or node negative (estrogen receptor (ER)/progesterone receptor (PR) negative or with one high risk feature) breast cancer:
Metastatic breast cancer
Metastatic gastric cancer
In combination with cisplatin and capecitabine or 5-fluorouracil, for the treatment of patients with HER2-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma, who have not received prior treatment for metastatic disease
Compendial Uses
All other indications are considered experimental/investigational and not medically necessary.
DOCUMENTATION
Submission of the following information is necessary to initiate the prior authorization review: human epidermal growth factor receptor 2 (HER2) status (where applicable), RAS mutation status (where applicable), BRAF mutation status (where applicable)
COVERAGE CRITERIA
Breast Cancer
Esophageal, Gastric, or Gastroesophageal Junction Cancer
Authorization of 12 months may be granted for treatment or palliative therapy of HER2-positive esophageal, gastric, or esophagogastric junction cancer in combination with chemotherapy.
Uterine Serous Carcinoma or Carcinosarcoma
Authorization of 12 months may be granted for treatment of HER2-positive stage III-IV, recurrent, or metastatic uterine serous carcinoma or carcinosarcoma in combination with carboplatin and paclitaxel and continued as a single agent for maintenance therapy.
Authorization of 12 months may be granted for treatment of unresectable, advanced, or metastatic colorectal cancer, including appendiceal adenocarcinoma and anal adenocarcinoma, when all of the following criteria are met:
Salivary Gland Tumor
Authorization of 12 months may be granted for treatment of recurrent, unresectable, or metastatic HER2-positive salivary gland tumors when used as a single agent or in combination with docetaxel or pertuzumab.
Biliary Tract Cancers
Authorization of 12 months may be granted for subsequent treatment of unresectable, resected gross residual, or metastatic HER2-positive biliary tract cancers (including intrahepatic and extrahepatic cholangiocarcinoma and gallbladder cancer) when used in combination with pertuzumab or tucatinib.
CONTINUATION OF THERAPY
Authorization of 12 months may be granted for continued treatment in members requesting reauthorization for an indication listed in the coverage criteria section when there is no evidence of unacceptable toxicity or disease progression while on the current regimen. Adjuvant and neoadjuvant treatment of breast cancer will be approved for a total of 12 months of therapy.
MEDICATION QUANTITY LIMITS
Drug Name |
Diagnosis |
Maximum Dosing Regimen |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Breast Cancer |
Route of Administration: Intravenous Initial: 4mg/kg once (7-day cycle) Maintenance: 2 mg/kg every week
Initial: 8mg/kg once (21- day cycle) Maintenance: 6 mg/kg every 3 weeks
4mg/kg once (7-day cycle), followed by 2 mg/kg every week through week 8, 12, or 18, then 6 mg/kg every 3 weeks to complete 52 weeks of therapy (Allowed up to 52 weeks of treatment for Adjuvant and Neo-adjuvant uses) |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
CNS Cancer : Brain Metastases |
Route of Administration: Intravenous 6mg/kg every week
Initial: 8mg/kg once (21-day cycle) Maintenance: 6mg/kg every 3 weeks |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
CNS Cancers: Leptomeningeal Metastases |
Route of Administration: Intrathecal, Intraventricular 150mg every week |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Colorectal Cancer, including or Appendiceal Adenocarcinoma and Anal Adenocarcinoma |
Route of Administration: Intravenous Initial 4mg/kg once (7-day cycle) Maintenance: 2mg/kg every week
Initial:8mg/kg once (21-day cycle) Maintenance: 6mg/kg every 3 weeks |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Esophageal Cancer, Esophagogastric Junction Cancer, or Gastric Cancer |
Route of Administration: Intravenous Initial: 8mg/kg once (21-day cycle) Maintenance: 6mg/kg every 3 weeks
Initial: 6mg/kg once (14-day cycle) Maintenance: 4mg/kg every 2 weeks |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Hepatobiliary Cancer, including Cholangiocarcinoma or Gallbladder Cancer |
Route of Administration: Intravenous Initial: 8mg/kg once (21-day cycle) Maintenance: 6mg/kg every 3 weeks |
Hercessi (Trastuzumab0 Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Salivary Gland Tumor |
Route of Administration: Intravenous Initial: 4mg/kg once (7 day cycle) Maintenance: 2mg/kg every week
Initial: 8mg/kg once (21 day cycle) Maintenance: 6mg/kg every 3 weeks |
Herceptin (Trastuzumab) Herzuma (Trastuzumab-pkrb) Kanjinti (Trastuzumab-anns) Ogivri (Trastuzumab-dkst) Ontruzant (Trastuzumab-dttb) Trazimera (Trastuzumab-qyyp) Hercessi (Trastuzumab-strf) |
Uterine Neoplasms - Endometrial Carcinoma |
Route of Administration: Intravenous Initial: 8mg/kg once (21 day cycle) Maintenance: 6mg/kg every 3 weeks |
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
ADDITIONAL INFORMATION
For appropriate chemotherapy regimens, dosage information, contraindications, precautions, warnings, and monitoring information, please refer to one of the standard reference compendia (e.g., the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) published by the National Comprehensive Cancer Network®, Drugdex Evaluations of Micromedex Solutions at Truven Health, or The American Hospital Formulary Service Drug Information).
REFERENCES
ORIGINAL EFFECTIVE DATE: 12/1/2016
MOST RECENT REVIEW DATE: 5/31/2025
ID_CHS
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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