CommercialPrior AuthMedium impact
Pertuzumab, Trastuzumab and Hyaluronidase-zzxf (Phesgo™)
BCBS Tennessee·TN · Oncology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a NEW medical policy for Phesgo™ (Pertuzumab, Trastuzumab and Hyaluronidase-zzxf), a combination biologic for HER2-positive breast cancer treatment. The policy covers three FDA-approved indications (neoadjuvant, adjuvant, and metastatic breast cancer) and allows substitution for IV pertuzumab/trastuzumab combinations. Prior authorization is required with HER2 status documentation, and initial authorization is limited to 12 months.
Action Required
By September 30, 2026: (1) Billing team must update billing system to require prior authorization for all Phesgo™ claims; (2) Configure system to mandate HER2 status documentation submission before claims processing; (3) Set authorization limit to 12 months for neoadjuvant and adjuvant treatment, with capability to track therapy duration; (4) Oncology providers must document HER2-positive status and treatment indication (neoadjuvant/adjuvant/metastatic) on all Phesgo™ requests; (5) Update prior auth submission forms to capture required HER2 status; (6) Train billing and clinical staff on three covered indications and continuation therapy criteria. Failure to obtain prior authorization will result in claim denials. Note: This policy does not take effect until 9/30/26—do NOT implement before this date.