Medicare AdvantagePrior AuthMedium impact
Perjeta (pertuzumab) (Revised)
Humana·FL, KY, SC · Oncology·Medicaid
Effective date
Jan 1, 2020
We identified it
Jun 25, 2026
Summary
This is a revised Perjeta (pertuzumab) prior authorization policy effective January 1, 2020, with the most recent revision dated January 28, 2026. The policy covers HER2-positive breast cancer treatment in three scenarios: neoadjuvant therapy for locally advanced/inflammatory/early-stage disease, adjuvant therapy for early-stage high-risk disease, and metastatic disease. Key requirement: treatment cannot exceed 52 weeks or 18 cycles. All uses require prior authorization and specific HER2 testing confirmation (IHC 3+ or IHC 2+/ISH positive).
Action Required
By February 28, 2026: Billing and clinical teams must verify this revised policy is implemented in all systems for Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. Confirm that all Perjeta (pertuzumab) requests trigger prior authorization workflows and that clinical reviewers are validating: (1) HER2-positive status per ASCO-CAP 2018 guidelines (IHC 3+, or IHC 2+/ISH positive), (2) appropriate diagnosis (locally advanced/inflammatory/early-stage >2cm or node-positive, early-stage high-risk, or metastatic), (3) correct combination therapy regimen (TCH, or trastuzumab with docetaxel/paclitaxel, or specific adjuvant combinations), and (4) treatment duration does not exceed 52 weeks or 18 cycles. Update prior authorization request forms to require HER2 test results and cycle tracking. Educate oncology providers on the 52-week/18-cycle cap. Claims submitted without prior authorization or exceeding treatment limits will be denied. Reference updated policy at Humana.com/PAL for claim code guidance.