Pertuzumab (Perjeta®); Pertuzumab-dpzb (Poherdy®)

By September 30, 2026: Billing team must implement prior authorization requirements for all pertuzumab/Poherdy claims in the BCBS Tennessee system. (1) Configure billing software to require prior authorization for all pertuzumab/Poherdy claims with effective date 9/30/26; (2) Create or update prior authorization submission templates to mandate collection of HER2 status, HR status, RAS mutation status, and BRAF mutation status before claim submission; (3) Update provider education materials and encounter documentation templates to flag required genetic testing results and clinical scenario documentation (neoadjuvant vs. adjuvant vs. metastatic, disease stage, prior treatment history); (4) Establish verification workflow to confirm clinical criteria are met (e.g., HER2-positive status, appropriate drug combinations with trastuzumab, applicable disease stage) before authorizing; (5) Train billing staff and providers on the specific coverage criteria for each cancer type (breast, colorectal, biliary, salivary gland, appendiceal, small bowel); (6) Configure 12-month authorization periods in system settings. Failure to obtain prior authorization before claim submission will result in claim denials. NOTE: This policy has a future effective date; implementation planning should begin immediately to ensure readiness by 9/30/26.